Revici Cancer Therapy Method - Doctor Emanuel Revici who cured cancer - Research in Physiopathology as Basis of Guided Chemotherapy: With Special Application to Cancer

Citation preview

RESEARCH IN PHYSIOPATHOLOGY AS BASIS OF^ GUIDED CHEMOTHERAPY With Special Application to Cancer EMANUEL REVICI, M.D. Scientific Director, Institute of Applied Biology, New York, N. Y. Chief of Dept, of Oncology, Trafalgar Hospital, New York, N. Y.

Published for the American Foundation for Cancer Research, Inc., by

D. VAN NOSTRAND COMPANY, INC. PRINCETON, NEW JERSEY TORONTO

LONDON NEW YORK

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

D. VAN NOSTRAND COMPANY, INC. 120 Alexander St., Princeton, New Jersey (Principal office), 24 West 40 Street, New York 18, New York D. Van Nostrand Company, Ltd.

358, Kensington High Street, London, W.14, England D. Van Nostrand Company (Canada), Ltd.

25 Hollinger Road, Toronto 16, Canada

Copyright © 1961, by

EMANUEL REVICI. M.D. Published simultaneously in Canada by D. Van Nostrand Company (Canada). Ltd. No reproduction in any form of this book, in whole or in part (except for brief quotation in critical articles or reviews), may be made without written authorization from the publisher. Library of Congress Catalog Card Number: 60-53061

PRINTED IN THE UNITED STATES OF AMERICA

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

CONTENTS

Foreword

xix

Theory and Facts

xix

The Present State of the Cancer Problem

xxii

1. Basic Concepts of Organization

1

Homotropy and Hcterotropy in Nature The Atom Homotropic and Heterotropic Forces in the Atom Fulfillment of Quantum and Electrostatic Forces Quantum and Electrostatic Forces in Molecules Binding of Molecules Polymolecular Formations Micelles Organization of Motion as Heterotropic Achievement Levels, Entities and Constituent Parts Principal and Secondary Parts The Organized Boundary 2. Biological Entities

17

Biological Realm Nucleolus Protoplasmatic Formations Boundary Formations Hierarchic Interrelationship Phylogenetic Development Constants Water Circulation Animals and Plants Multiplication

Digitized by

Goo

2 3 4 5 6 9 9 10 11 12 13 16

20 23 23 23 24 24 28 30 30 31 v

Original from

UNIVERSITY OF MICHIGAN

vi

/

CONTENTS

Life and Death Maintenance of Constants Dualism Normal and Abnormal

32 33 35 36

3. Cancer as an Organized Condition Precancerous Phase Noninvasive Phase Invasive Phase Painful Phase Preterminal and Terminal Phases

38 39 39 40 40 40

4. Dualism

43

Pain

43 43 43 45 46 52 55 59 60

Dualism in Pain

Physiological and Pathological Pain Dualism in Pathological Pain

Pain and Acid-Base Balance Changes Acidifying and Alkalizing Agents Dualism in Local pH Measurements Oxido-reduction Potential Abnormal Substances

61

Other Acid and Alkaline Symptoms

Itching Vertigo Impaired Hearing Manic-depressive Condition Dyspnea Dualistic Patterns at Other Levels

Cellular Level Tissular Level Organic Level Systemic Level Temperature Systemic Analyses Blood Urine Urinary Patterns Fundamental Offbalances Place of Dualism in Cancer Physiopathology 5. The Constituents

104

The Elements The Series Periods

Digitized by

Goo

61 67 73 75 77 82 82 83 83 83 83 85 86 86 90 93 99

105 105 107

Original from

UNIVERSITY OF MICHIGAN

CONTENTS

6. Lipids and Lipoids

/

vii

113

Definition of Lipids

114

Physical Lipoidic Properties

119

Solubility Molecular Layer Formation

119 123

Chemical Properties Biological Properties

124 125 125

Lipidic System Fatty Acids

128

Rancidity Caloric Metabolism Constitutional Role Functional Role Double Bonds

128 129 130 130

131

Abnormal Fatty Acids

132 134

Methods of Investigation Used The Anti-Fatty Acids

135

Glycerol and Glycerophosphoric Acid

135 137

Steroids Sex Hormones Sterols Steroids with a Two-Carbon Chain

139 141 143

The Luteoids Corticoids

143

Glucuronic and Sulfuric Anions

144 147

Fatty Acids vs Anti-Fatty Acids

148

Sex Age Other Physiological Factors Effects of Antagonistic Lipids at Different Levels Effects of Lipids on Viruses Effects of Lipids on Microbes Effects of Lipids on Protozoa Effects of Lipids on Complex Organisms On Pain Wound Healing Regeneration Organic Level Intestines Kidney Nervous System Convulsions Coma

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

149 150 150 154 154 157 158 159 160 161 161 162

162 162 163 163

163

Viii

/

CONTENTS On Cardiac Rhythm On Oestral Cycles Systemic Level On Temperature On Systemic Patterns Mechanism of the Lipidic Biological Activity

164 164 164 164 165 165

Other Constituents

168

Aminoacids Carbohydrates

168 170

7. Defense

171

Diphasic Phenomenon Prolonged Hemoshock Anti-heterogenous Reaction Coagulant Antibodies Allergic Reaction Lipido-Proteic Antibodies Neutralizing Antibodies Defense and Hierarchic Levels Clinical Manifestations Organization and Defense Affinity of Antieens Allergic Precipitates Intermediary Lysates

172 176 177 179 180 181 182 183 184 186 189 193 194

Infectious Diseases

195 195 198 199 201 202 202 203 204

Toxic and Allergic Conditions

Pneumococcic Pneumonia Diphtheria Typhoid Tetanus Rabies Syphilis and Tuberculosis Streptococcal Infections Immunological Defense Against Cells and Tissues

Heterogenization of the transplants 7th day Manifestations in Trauma

206 210

Immunological Problems in Cancer

212

Grafts in Humans Metastases Immunological Therapeutic Approach

Digitized by

Google

206

214 217 218

Original from

UNIVERSITY OF MICHIGAN

CONTENTS

/

8. The Correlation Between the Basic Concepts

ix

221

Hierarchic Organization Constituents Dualism

221 222 223

9. Shock

225

Types of Shock Shock Mechanism Pathological Changes Fatty Acids and NaCl in Shock Water Metabolism Other Changes Experimentally Induced Shock

225 227 227 229 232 233 233

10. Radiation

236

Irradiation of Lipids Irradiation in Vitro Irradiation in Vivo Local Effects Lipids and Radiation Burns

236 238 242 249 252 256 257 258 261 262

Role of Anti-Fatty Acids

Role of Adrenals Direct Action of Radiation Radiotherapy Biologically Guided Radiotherapy

11. Problems in Cancer

264

Diagnostic Tests Circulating Cancer Cells and Surgery

265 267

Experimental Carcinogenesis

268

Energetic Factors Twin Formation Nitrogen Mustard Derivatives Epoxide Carcinogens Synjugated Formations

270 271 278 281 283 290

Viruses and Cancer

Two Types of Carcinogenic Effects Plural Activity Virus and the Host Virus and Lipoids

Digitized by

Goo

290 293 295 296

Original from

UNIVERSITY OF MICHIGAN

X

/

CONTENTS

302 302 304 307

Genetics and Carcinogenesis

Allotropic Resonance Forms Lipids and Carcinogenesis Carcinogenic Activity of Urethane Intervention of Psychological Factors in Cancer Patho¬ genesis

308

12. Pharmacodynamic Activity

311

312

Agents with Active Negative Polar Groups

312 312 313 317 319 324 325 326 326 327 328

Fatty Acids

Saturated Fatty Acids Unsaturated Fatty Acids Acid Lipidic Fractions Abnormal Fatty Acids

Bixine Fading Response Alpha Hydroxy Fatty Acids Other Fatty Acids Peroxide Fatty Acids Halogenic Compounds of Fatty Acids Lipoids with Other Negative Polar Groups

329

Lipoaldehydes

329

Lipoids with Thiol Groups

330

Mercaptans Hydropersulfides Other Compounds with a Thiol Group Tetrahydronaphthalene Persulfides Thiosulfates Alpha-Thio-Fatty Acids Thioglycolic Series Relationship to Sulfur Metabolism

330 334 335 336 336 338 338 340

Selenium Lipoids

342

Hexyl- and Heptydiselenides Tetrahydronaphthalene Perselenide

343 344

345 346 348

Alkylating Agents

Sulfur Mustard Epichlorohydrin The Elements

349

Magnesium Calcium Copper Manganese and Cobalt

Digitized by

Google

354 356 358 360

Original from

UNIVERSITY OF MICHIGAN

CONTENTS

/

Heavier Elements Elements in the Pathogenesis of Cancer

Xi

361 361

13. Pharmacodynamic Activity (Part Two)

362

362

Anti-Fatty Acid Group

Anti-Fatty Acids Constituents Glycerol Glucose Glycerophosphoric Acid Sterols Insaponifiable Fractions Corticoids Synthetic Anti-Fatty Acids

Butanol Higher Alcohols Polyols Diols Lipoalcohols with Energetic Centers in the Nonpolar Group Other Alcohols Lipamines

Procaine The Elements

Monovalent Cations Sodium Potassium Iron Zinc Mercury Bismuth Arsenic Aluminum Chlorine Fluorine and Bromine Iodine Oxygen Peroxidases Antioxidants

14. Therapeutic Approach

362 363 368 368 369 371 372 375 375 380 387 387 388 389 390 391 394 395 395 396 399 401 402 402 402 403 403 404 404 405 409 409

413

Biological Guided Therapy

413

Criteria The Agents Method of Application Evaluation

415 416 416 417

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

Xii

/

CONTENTS

Therapeutic Applications in Conditions Other Than Cancer

418 420 421 423 426 428 430 435 435 435 437 439 439 441 441 450 451 452 457

Acid Base Manifestation Pain Trauma Burns Vertigo Hearing Impairment Itching Gallbladder and Renal Colic Arthritis

Connective Tissue Condition Hemorrhage

Hemorrhagiparous Agents Antihemorrhagic Agents Butanol Fatty Acids A llergic Conditions A rteriosclerosis

Therapeutic Attempts 15. Therapeutic Approach to Cancer Placenta Extracts Cod Liver Oil Fatty Acids and Sterols Acid Lipidic Fractions and Unsaponifiable Group of Agents Mercaptans Sulfurized Oil Thiosulfates Hydronaphthalene Persulfides Butanol, Glycerol Conjugated Fatty Acids Heterogeneous Agents Selenium Preparations Tetralin Perselenide Radiation and Chemotherapy

461 463 466 468 473 476 481 482 491 493 501 508 512 518 524

16. Present Form of Treatment

531

Criteria Used Conduct of Treatment Results Obtained

532 536 537

Bibliography

727

Index

747

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

NOTES

Chapter 1 NOTE

543

1. Subnuclear Organization Chapter 2 NOTE

545 547 548

1. CNCN 2. Repartition of Potassium and Sodium 3. Social Hierarchic Organization Chapter 3 NOTE

550 550 551

1. Precancerous Lesions 2. Noninvasive Cancer 3. Abnormal Amino Acids Chapter 4 NOTE

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.

Physiological and Pathological Pain Blood Titrimetric Alkalinity and Urinary pH Acid Pattern of Pain and Lactic Acid Itching Nasal pH Wheal Resorption Eosinophiles Total Blood Potassium Sulfhydryl Determination Calcium in Urine Urinary Surface Tension Technical Problems Design and Calibration of the Urotensiometer

552 557 561 562 565 566 567 571 573 575 575 575 578 • • •

X1U

Digitized b

Google

Original from

UNIVERSITY OF MICHIGAN

Xiv

/

NOTES

NOTE

The Measurement of Urinary Surface Tension with the Urotensiometer The Nature of the Intervening Substances Surface Tension and Normal and Abnormal Physiology Time of the Day and Urinary Surface Tension Surface Tension in Normal Humans and Animals Colloids in Urine and Surface Tension

12. 13. 14. 15. 16.

Urinary Oxydoreduction Potential Oxydoreduction Potential of the Urine Peroxides in the Urine Index of Excretion and Retention Water and Nitrogen Metabolisms

578 580 581 581 584 590 590 590 592 594 595

Chapter 5 NOTE

1. Second Day Wound Crust pH

597 599 599

Chemical Factors

Cations and Anions Acid Lipoids Alcohols Other Agents

601 601 603

Physical Agents

607

Biological Factors

608

2. Potassium

610 612 613 615

Potassium and Off balances Potassium and Lipids Potassium and Therapy Chapter 6 NOTE

1. 2. 3. 4. 5. 6. 7.

Definition of the Lipids Definition of Lipoids Separating Membrane Between Aqueous Media Fatty Acids Break Down Position of the Double Bond in Monoethenoids Saturation—Desaturation Balance in the Liver Essential Fatty Acids 8a. Solvent Fractionation of the Lipidic Constituents 8b. Spectral Analysis 8c. Vapor Fractionation of Fatty Acids 8d. Fixation of Halogens on Conjugated Double Bonds 9. Twin Formation 10. Arachidonic Acid—Sterol Relationship 11. Steroids Deriving from Arachidonic Acid 12. Steric Coupling 13. Luteoid Function

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

615 615 616 616 618 619 621 622 626 627 622 627 631 631 633 633

NOTES

/

XV

NOTE

14. 15. 16. 17. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42.

Energetic Center in Steroids Relationship Between Corticoids The Template Hypothesis Adrenal Defense Index Bonds of Glucuronic Acid Glucuronic Acid—Mechanism of Coupling Paraplegia Induced by Cholesterol Adipose Cells and Sulfur Mustard Fatty Acids and Old Tetrahymena Lipids and Old Age Surface Tension of Urine in Old Age Environmental Influences Environmental Influences Upon Urinary Surface Tension Barometric Influence Lipoids and Tumor Transplants Temperature, Lipids and Virus Infection Youth and Viruses Changes in the Viruses Induced by Lipids Microbes, Phages and Lipids Lipids and Survival Time of Tetrahymena Lipids, Temperature and Tetrahymena Pain Induced by Lipids Lipids and Wound Healing Liver Regeneration Lipids and Convulsions Lipoids and Coma Cardiac Rhythm Some General Considerations of the Role of Lipids in Blood Physiology Sedimentation Rate Red Cell Volume Red Cells, Plasma and Lipids Lipids and Oxygen Transport Lipids and Shock Effects upon Leucocytes Lipids and Blood Serum Cholesterol

635 637 636 638 641 641 644 645 646 646 646 649 651 653 653 654 654 655 656 656 657 657 657 658 659 659 660 662 663 664 664 667 667 668 668

Chapter 7 NOTE

1. 2. 3. 4. 5. 6. 7.

Analyses in Studying the Hemoshock Morphine and Shock Physical Exercise and Shock Lymphocytes and Effects in Vitro Lipids and Immunity Microbes Treated with Lipids Skin Allergy

Digitized by

Goo

669 670 671 671 671 671 673

Original from

UNIVERSITY OF MICHIGAN

XVi

/

NOTES

Chapter 9 NOTE

1. 2. 3. 4. 5. 6. 7.

Hemoglobinuria a Frigore Lipids and Rouleaux and Sludge Formation Dark Color of the Blood in Shock Induction of Acute Shock Induction of State of Shock Influence of Fatty Acids upon Traumatic Shock Influence of Unsaponifiable Fractions upon Traumatic Shock

673 678 678 679 679 679 680

Chapter 10 NOTE

1. 2. 3. 4.

Oxalic Index Irradiation and Oxalic Index Oxalic Index in Sublethal Irradiation Radiation Induced Offbalances

680 682 682 683

Chapter 11 NOTE

1. Carcinogenic Activity of Urethane 2. Constitution of Viruses

689 690

Chapter 12 NOTE

1. 2. 3. 4.

Lipids and Cytolytic Activity of Sera Fatty Acids Transportation in the Blood Conjugation Method Quenching Action and Anti-Carcinogenic Effect of Conjugated Fatty Acids Conjugated Fatty Acids and Quenching Conjugated Fatty Acids and Induced Carcinogenesis

5. 6. 7. 9.

Lipids and Tumor Chlorides a-OH Fatty Acid and Experimental Tumors Hydropersulfides Magnesium and Adrenalectomy

691 694 695

695 699 703 710 710 711 712

Chapter 13 NOTE

1. 2. 3. 4. 5. 6. 7.

Glycerol and Chills Influence of Glycerol upon the Cardiac Rhythm Glycerol Induced Convulsions Suspensions of Lipoids Cholesterol Induced Convulsions Treatments in Successive Generations Conjugated Trienic Alcohols

Digitized by

Goo

713 714 714 715 715 715 718

Original from

UNIVERSITY OF MICHIGAN

NOTES

/

xvii

NOTE

8. 9. 10. 11.

Toxicity of Butanol in Humans Butanol and Leucocytes Butanol-sodium lactate in Bums Effect of Heptanol

718 719 720 721

Chapter 14 NOTE

1. 2. 3. 4. 5. 6.

Observations of Dr. E. Stoopen Dr. Welt’s Publication on Butanol Dr. A. Ravich’s Conclusions Treatment of Post-Traumatic Conditions Dr. B. Welt’s Conclusions on Hearing Butanol in Plastic Surgery

721 723 723 723 724 725

Chapter 15 NOTE

1. Radiation and Chemotherapy

Digitized by

Goo

726

Onginal from

UNIVERSITY OF MICHIGAN

To My Wife

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

FOREWORD

THEORY AND FACTS

IP*ew other pathological conditions

have aroused, as cancer has, the

interest of so many scientific disciplines. Problems related to cancer have become of continuously increasing concern in virtually every field of medi¬ cine. In some, such as pathology, they are a major preoccupation. But in sciences other than medicine, cancer also has been receiving increased atten¬ tion. One of the most urgent activities of synthetic chemistry today is the search for new compounds which might possibly be effective in the control of cancer. Physical chemistry is trying to provide new explanations about the variety of processes present in cancer. Even mathematical studies which recently have offered an interesting application of quantum theory to carcin¬ ogenesis, have found new applications in cancer. With the rapid development of physical sciences, the medical research worker has hoped that from them might come some contribution that could help him ultimately in his difficult task. He also appears to have been anx¬ ious to take quick advantage of the progress of other disciplines for another reason, hoping that, through employing their findings and methodology, medicine in general and cancer research in particular, could be promptly changed from the empirical discipline it has been until now into a positive science. He has brought as many applications of other disciplines as possi¬ ble into his study and this has led to a whole series of new methods of investigation through which interesting new information has been obtained. Yet, most of these applications have been tried chiefly because they have been at the immediate disposal of the scientist rather than because they have represented a missing link in the development of his own ideas. The outcome has not been rewarding. Medical knowledge appears not to be sufficiently advanced to successfully utilize the avalanche of new, highly specialized information offered by the investigative methods derived

xix

Digitized by

Goo

Onginal from

UNIVERSITY OF MICHIGAN

XX

/

FOREWORD

from other disciplines. Basic theoretical knowledge in medicine in general, and about cancer in particular, has not yet reached the level necessary to relate and assimilate the new data. To a large extent, basic concepts about pathogenic problems are not even formulated as yet. When the medical scientist has tried to transform the new data into effective therapeutic pro¬ cedures, he has failed. And the failure has made more evident how much we need basic physiopathological knowledge before we are able to take advantage of detailed data. Meanwhile, normal development of cancer research has been hindered, side-tracked from its logical course. While thousands of scientists with almost unlimited funds at their disposal are presently using the most ad¬ vanced methods for the acquisition of details, almost no attempts are being made to resolve basic problems, although the cancer investigator is con¬ tinuously obliged to realize the dearth of fundamental knowledge. If we attempt to analyze this abnormal situation further, we can find indications that it may have its origin also in a distortion of the proper relationship between the two factors that, together, make for progress in re¬ search—ideas and experiment. The experimental approach provides precise information about particu¬ lar phenomena under defined conditions. The analytical method tries to investigate reality by recognizing the proper place of the various constitu¬ ents of a whole, the parts being identified as such by the experimental findings. On the other hand, the conceptual method not only provides an inkling of what the completed whole will eventually look like, but also attempts to predict the properties and the relationship of the component parts. In dealing with a highly refined and complicated subject, the analytical method by itself appears inadequate. For example, in atomic physics, the results of experiments are expressed by numbers giving the values of cer¬ tain physical quantities that have been measured. In order to complete the analysis, we must simultaneously determine the numerical values of certain quantities defining the material bodies, the objects of the experiments. This is prohibitive so far as canonical coordinates by Heisenberg’s uncer¬ tainty principles are concerned. With experimental knowledge somewhat curtailed, theory at present must attempt explanation. In other areas as well, experiments present only limited numerical values pertaining to some physical quantities. Were we able to measure all quantities, we could analytically reconstruct the entire theme of the physical reality. However, when some quantities cannot be simultaneously deter-

Digitized by

Google

UNIVERSITY OF MICHIGAN

FOREWORD

/

XXi

mined, this direct reconstruction is not possible and experiments merely give an indirect approach to what we regard as “reality.” If the inadequacy of the analytical approach by itself is evident in the highly positive disciplines, such as in the physical sciences, it is even more so in biology. As Bohr and others have intimated, the conditions of uncertainty seem to be much more pronounced in biology than in physical science. The fact that experiments in biology give only fragmentary and unrelated results is not surprising; the need for a synthetic theoretical method in this field is clear. In medicine, which is applied biology, the need for the conceptual ap¬ proach is especially profound. It is true that this approach, as the sole approach, has shown its inherent weakness in the past. There was a time in the development of medicine when available data were so scarce and unreliable, and the need for ideas to provide some sort of guidance was so great, that the worker resorted to broad imagination, using it to replace almost entirely any other form of investigation. Largely as a reaction to the high proportion of “speculations” preva¬ lent in the early years, the experimental approach in medicine came to be emphasized. Claude Bernard, who almost single-handedly was responsible for this, tried to give experimentation its rightful role. However, in ensuing decades, the relationship between theory and experimentation has been progressively distorted. An unrestrained exaggeration of the role of the experiment, the erroneous view that pure facts represent the aim of re¬ search, has led to an entirely unbalanced approach. Not only have almost any data obtained by research been considered intrinsically interesting, but obtaining them has become the sole purpose of much research. In scientific papers today, experimental data must be reported as such; any allusion to theoretical meaning is considered undesirable. Generations of scientists have been schooled to believe in the intrinsic value of the experiment. As they have applied this belief to research in biology, and as they have made unlimited use of new methods taken from other disciplines with no ideo¬ logical requirement for their use, we have had more and more data and fewer ideas. Today, with great astonishment, some scientists are at last beginning to recognize not only that data alone do not generate ideas, but that science cannot progress without theory. Ideas and experiments are integral parts of all scientific research. A balance between them is needed to assure progress. It must be understood that the function of experimentation is to guide our thinking, to help build up new concepts, and to prove their accuracy in accordance with reality. Certainly, fundamental concepts must not be mere “speculations.” They

Die

J2LCU L

Google

UNIVERSITY OF MICHIGAN

XXii

/

FOREWORD

should be accepted only after confirmation through experimentation. Ex¬ perimentation is the necessary link between mental concept and reality. To the attempts to consider any unresolved fundamental problems in biology, one has to try to bring a rightful balance between conceptual views and experimentation. The exaggerated importance attributed to experimentation in biological science, its use even as a substitute for ideas, has led recently to a massive attempt to solve the therapeutic problem of cancer by indiscriminate screening of chemical agents. Here, empiricism has been brought to its culmination. After tests of tens of thousands of agents, many workers are now beginning to realize that the results are almost worthless for cancer therapy in humans, that seemingly promising agents have an effectiveness limited to the conditions present in the actual animal experiments. By its impressive magnitude, the failure of indiscriminate screening, of empiri¬ cism epitomized, has begun to impel many workers to change their idea as to what must be done if the cancer problem is to be solved. A first result of this change has been a new and, this time, unbiased evaluation of just where we stand in our assault on the cancer problem. Every day more scientists are making the evaluation in their reports to the medical profes¬ sion and to the public with a candidness which, only a few years ago, very few would have employed.

The Present State of the Cancer Problem Surgery in cancer can be considered to have arrived now at or near its maximum efficiency. Thanks to progress in operative techniques, and to advances in pre- and post-operative care, ultraradical surgery is available today. The propensity of cancer to spread far from its original site has made such surgery obligatory in many cases if there is to be an effort to eliminate all malignant cells. Yet ultraradical surgery has not sufficiently increased the cure rate to justify horrifying mutilations, especially when the face is involved. With few exceptions, surgical procedures do not pre¬ vent the patient from dying of cancer sooner or later. The so-called fiveyear-cure-rate represents, to say the least, an unrealistic appraisal. Many authors consider that even the rate of five-year survival is not improved by surgical procedures, and the ultimate fate of these five-year survivors, with few exceptions, is still disastrous. Most of the “cured” cases still die from cancer. Other recently discovered facts have increased skepticism about the value of surgery in cancer. The polycentric origin of cancer, especially in

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

FOREWORD

/

xxiii

cases where the lesions are far apart—considered by some workers to be true even in malignant melanoma, for instance—would greatly limit the value of surgery as a means of eliminating all cancerous cells. It is recog¬ nized that to operate on a lymphoma is useless. Furthermore, it is known today that cancer cells are present in the circulating blood. Surgical manip¬ ulation has been found to induce a flow of these cells into the blood even from relatively small primary tumors. In view of all this, cancer cannot be considered to be a condition for which surgery is a major hope. Surgery represents only an expedient—to be tried so long as nothing better can be offered. It is probable that in the future it will be reserved, in cancer treatment, for the correction of me¬ chanical complications, such as intestinal or other duct occlusion. Unfortunately, radiation has not been much more successful in its long range results. In order to control cancer, it is necessary that radiation de¬ stroy all the cancer cells present in the organism while producing minimal damage to normal tissue. It appears that such high selectivity of action cannot be obtained. The lack of it may be implicit in the nature of the effects achieved by radiation. A study of the biological effects of radiation, which is to be presented later in this monograph, has shown that an important part of the action of radiation is to induce changes in certain constituents of the body, principally fatty acids. These changes are largely responsible for the favorable effects of radiation but they also are largely responsible for the undesired effects. It is the nature of these changes which limits qualitatively the capacity of radiation to influence cancerous proc¬ esses, and makes it dubious that progress in technique can ever greatly improve the qualitatively insufficient effectiveness of radiation. Clinical results to date provide confirmation of this pessimistic view. The recent use of extremely high voltage radiation, of radioactive cobalt, and of other radioactive particles has not greatly improved results over those obtained with older forms of radiation twenty years ago, except for reducing some harmful immediate skin and systemic effects. Now, as earlier, with few exceptions, the benefits of radiation are no more than temporary. Long lasting good effects still are limited to only a few radio-sensitive tumors. The resort to isotopes, in which the scientific world has put so much hope and millions of dollars, also has proved greatly disappointing. Of the thousands of cases of various kinds of cancer in which isotope therapy has been tried, only a very limited number of cancers of the thyroid have responded. Not only because of its continuing failures, but because of its inherent qualitative inadequacy, radiation does not appear, any more than surgery, to represent the solution for the problem of cancer.

original rrom Digitized by GoOglC

UNIVERSITY OF MICHIGAN

XXiv

/

FOREWORD

With surgery and radiation therapy incapable of resolving the problem, more and more research workers have turned their efforts in other direc¬ tions. The existence of some cases of spontaneous remission has led many investigators to believe that immunological procedures related to cancer would be able to resolve these problems. Unfortunately the existing knowl¬ edge in this specific field is too meager to permit more than some tentative investigations, usually only repetitions of similar researches made many years ago with limited success. Fruitful development of this approach would have to follow the normal pathway, starting with more knowledge of the complex immunological processes intervening in cancer. An enormous amount of cancer research in recent years has been di¬ rected toward chemotherapy. It is a fact that many agents and groups of agents have shown the capacity to influence tumor evolution. However, each has had limited usefulness. Results of treatment have been character¬ ized by inconsistency. Even in seemingly susceptible types of cancers, results have been good in one case, poor in another and have varied even for the same patient at different times. The inability to explain and remedy these variations has discouraged many workers. Although it appears evi¬ dent that the source of discrepancies resides in the patients themselves, the general tendency among researchers has been to try to resolve the problem by finding agents able to act independently of any differences which exist between subjects. In despair at the lack of progress in this approach, many workers today are using the screening enterprise mentioned above as a kind of last resort. For this project, they have renounced the scientific concept that pharmaco¬ dynamic activity must serve as the basis on which an agent is to be tried in therapy. They have fastened into a purely empiric approach. Now, all avail¬ able chemical substances—and many others which will be synthesized especially for the purpose—are to be screened indiscriminately, for their effects on animal tumors with no reason for this test other than that the agents are, or can be made, available. We will not dwell here on the as¬ sumption that routine technique is more likely than imaginative brain power to resolve the problem of cancer. The results of this screening to date have shown it to be an invalid procedure, as expected by most critical workers. With tens of thousands of substances already tested, the busy screeners are obliged to recognize that the approach itself is fundamentally erroneous. Experience has proved that an agent can be wonderfully effec¬ tive against one tumor and still be entirely inactive in others. Of tens of thousands of agents tested, less than a hundred have shown effects on

tized b> Google

UNIVERSITY OF MICHIGAN

FOREWORD

/

XXV

tumors in animals. None appears to have significant value when applied in humans. These results have emphasized again the importance of factors other than the agent itself. One factor lies in the differences which exist between various tumors. Some of the other factors include variations between spe¬ cies, between individuals of the same species, between origins of tumors, between spontaneous and transplanted tumors, and even variations in any one individual at different times. Faced with this situation, some workers have concluded that not one treatment but at least hundreds of different treatments must be found in order to cope with the huge variety of conditions. Taking cognizance of these considerations, it has seemed to us that a more realistic and logical approach is to try to understand the nature of the existing differences and to attempt to make the treatment adequate on the basis of that understanding. It has been this approach which has been followed in our research. We have studied the problem of cancer for the last thirty years from an entirely different vantage point than that used by other workers. Atten¬ tion has been focused on the physiopathological aspect of cancer, on the basic changes that occur in the different patients, with the ultimate aim of understanding the part played by these changes in the response of cancer to therapeutic attempts. This emphasis on the physiopathological aspect of cancer has been made possible by applying a more general overall idea of the nature of the disease. This approach is based under various new concepts. They concern, 1) The role of the organization in the pathogenesis of the conditions. 2) A dualistic systematization of the manifestations related to normal and abnormal physiology. 3) The predominant intervention of certain constituents such as lipoids and chemical elements in the induction of the opposite manifesta¬ tions. 4) The possibility to integrate the occurring processes into a system of defense mechanism against the noxious influence exerted by the

environment Many general and special problems of physiopathology, some of them con¬ cerning cancer and other conditions, have been analyzed in this framework. The application of this approach to therapy has resulted from a logical development of that approach. The recognition of the intervention of a variety of pathogenic factors, not only differing from one subject to the other, but even changing in the same subject during the evolution of the

Digitized b

Google

Original from

UNIVERSITY OF MICHIGAN

XXVi

/

FOREWORD

condition has emphasized the need for individualized therapy. As opposed to the tendency to overcome the differences existing between individual subjects through a standard therapy, the “guided therapy” utilizes the knowledge of the occurring different pathogenic particularities in order to correct them. A high degree of flexibility in the treatment has appeared necessary. As part of this approach to therapy, has appeared the need for more complete knowledge of the existing differences and their interpretation in terms of the pathogenesis of the condition. The search for adequate analyti¬ cal tests has thus represented the first task. The development of day-by-day analysis of the condition has been possible by choosing relatively simple but reliable procedures. The information they offered was used to determine the nature of the agents able to correct with a certain specificity, the encoun¬ tered pathological conditions. These two parts, the recognition of the exist¬ ing condition and the adequate agents, have concretized this approach. These considerations explain also why the new developed “guided ther¬ apy” cannot be understood and correctly applied without a sufficient knowl¬ edge of its physiopathological and pharmacological basis. These same considerations have led us to present the research concerning this approach as a block, instead of fragmented communications. The form of a mono¬ graph has appeared consequently the best suited. In a further effort to achieve a cohesive presentation, we have separated from the text most of the technical and experimental data, and presented them as notes at the end of the text.

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

ACKNOWLEDGEMENT

Progress in our research has been made possible only through the day by day cooperation of different groups of co-workers who have contributed years of assiduous work. Many of them are mentioned in the following pages where the research in which they took part is presented. I am deeply indebted to them. I wish to thank all those friends whose personal efforts or, who through their organizations, have given their material and moral support to the continuation of our research. Special thanks go to Mrs. Sherman Pratt for her tireless efforts on our behalf. My sincere appreciation to those who have helped me in the preparation of this book, Mr. L. Galton, Mrs. E. F. Taskier and Mrs. H. Kennedy for the editorial work; Mrs. E. F. Taskier for the figures; and Mrs. P. Berger, Mrs. B. Doctors and Mrs. M. Prikasky for the secretarial work. I wish to gratefully acknowledge Miss Fanny Holtzmann’s devoted friendship and help.

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

CHAPTER

BASIC CONCEPTS OF ORGANIZATION

T» intellectual mechanism

used by man to acquire knowledge has led him to recognize the existence of relationships between the various manifestations encountered in nature. He has employed abstraction and integration to build up conceptual individualities which he identified as separate entities in nature. Structural characteristics and dynamic proper¬ ties have appeared to be the most suitable criteria for defining these enti¬ ties. However, curiosity has constantly impelled man to attempt to extend his knowledge by explaining and correlating these entities, and an impor¬ tant means has been analyses breaking them down into their component parts. Out of these analyses has come recognition of the fundamental im¬ portance of organization. For, as entities have been analyzed one after the other, it has become clear that the seemingly infinite variety of them per¬ ceived by our senses is in reality the result of the arrangement of a rela¬ tively small number of basic units, the molecules. Moreover, analysis has shown that only a very small number of chemical elements make up even the most complex molecules; that combinations of less than one hundred elements, in different proportions and relationships, account for tens of thousands of compounds and many billions of entities. And further analysis has revealed that elements themselves represent different dynamic arrange¬ ments of only a few—according to some hypotheses, only two—funda¬ mental corpuscles. Upon close analysis, nature, which appears to be so greatly varied, turns out, in fact, to be based upon only a very few fundamental constitu¬ ents and it is the manner in which these constituents are bound together, their organization into a multitude of combinations, which provides variety. 1

Digitized by

Goo

Onginal from

UNIVERSITY OF MICHIGAN

2

/

RESEARCH

IN

PHYSIOPATHOLOOY

The study of organization obviously, then, could furnish the most valu¬ able information about nature. And it would not appear to be too much to expect that, if nature’s seemingly infinite variety stems from organization of only a few constituents, then organization itself might also be achieved through a few, relatively simple fundamental patterns. If so, seeking out such patterns—systematic analysis of organization comparable to the efforts to systematize constituents—could be of primary importance to better understanding of a host of problems. Homotropy and Heterotropy in Nature

As man attempted to recognize order in the constant changes seen in nature, he noted certain patterns that appeared to indicate definite “laws of nature.” Some of these laws have been observed to operate under such a wide variety of circumstances that they have come to be accepted as “fundamental laws.” In 1824, Sadi Carnot formulated one which is known as the Second Law of Thermodynamics. Carnot observed that, in a given system, work involving the transformation of thermal into mechanical energy is only accomplished as heat drops from high to low temperature. In more general terms, this means that work accomplished in an isolated system results in progressively eliminating differences in temperature. Clausius recognized this as a fundamental principle and postulated that the amount of energy available for work always tends toward a maximum. This condition, called “maximum entropy,” corresponds to uniformization of temperature and also to homogeneous disorganization. At first, it appeared that the princi¬ ple was in conflict with the First Law of Thermodynamics which expresses the rule of conservation of energy. However, Helmholtz soon was able to demonstrate its validity by showing that only the second law could reconcile the first with the impossibility of perpetual motion. In a more philosophical vein, we considered, in our research, that this Second Law of Thermodynamics in its broadest sense could define a fundamental trend toward annihilation of any existing differences in na¬ ture, through the triumph of total uniformity. Since Clausius used the term “entropy” in applying Carnot’s original observation to closed mechanical systems, it has seemed preferable to avoid confusion by utilizing another term for this general tendency toward uniformity in its broadest sense. Therefore, we have chosen the term “homotropy.” Despite the theoretically rapid trend in the direction of absolute uni¬ formity, or homotropy, no such final state has yet been achieved. It must be concluded, therefore, that some other factor opposed to that trend exists.

Digitized by

Got >gle

UNIVERSITY OF MICHIGAN

BASIC

CONCEPTS

OF

ORGANIZATION

/

3

We have chosen the term “heterotropy” for this other factor, which tends to maintain or produce inequality and thus to preserve the order that is evident in nature. In order to understand the roles of these two opposing fundamental tendencies in the organization of nature in as logical a fashion and with as much ease as possible, it seemed advisable to try to study their opera¬ tion first in one of the simplest and best known natural organizations, the atom, passing later on to higher and lower levels of organization. The Atom

The role of the two opposing tendencies in atom organization becomes clear when we study the relationship between the forces that form this entity. Each atom consists of a positively charged nucleus surrounded by negatively charged electrons in adequate number to balance the nuclear charge. The existence of the atom depends upon forces acting between nucleus and electrons. One group is of coulombian nature. These are the electro¬ static forces that account for the attraction between oppositely charged electrons and nuclei, and for the repulsion between electrons bearing simi¬ lar charges. If such forces did not exist, electrons would wander irregularly and would not be retained around the nucleus. Yet, if electrostatic forces were unopposed, electrons would be drawn closer and closer to the nucleus and would finally fall into it, thereby bring¬ ing about complete annihilation of all charges. The fact that electrons are not absorbed by the nucleus indicates the existence of a second, opposing force. This second force is defined by quantum mechanics and the quantum theory of fields. Quantum mechanics ascribes a series of discrete energy levels to electrons within atoms. Radiation is emitted or absorbed only when electrons pass from one stationary level to another. The energy levels are relatively stable, and a state of minimum energy exists when each of the electrons of the atom is as close as it can be to the nucleus on the ground level. The energy levels correspond to the orbits described by Bohr’s theory which, although not entirely accurate, affords a good basis for understand¬ ing atomic properties. Bohr envisaged the electrons revolving around the nucleus in definite orbits, each orbit moving continuously in these states, the atom not emitting radiation. This differs from the older theory accord¬ ing to which the electrons can revolve around the nucleus on any orbit. Such casual orbit motions would lead to loss of energy by radiation. The

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

4

/

RESEARCH

IN

PH YSIOPATHOLOOY

electrons would come closer and closer to the nucleus and would, as already pointed out, finally be absorbed by it. The quantum theory of fields accounts for the absence of radiation and for electrons remaining in their particular orbits. However, the concept of stationary states fails to explain all the properties of the atom, particularly its chemical reactivity, by virtue of which different atoms combine to form molecules. According to another tenet of the quantum theory, the Pauli Exclusion Principle, an orbit cannot be occupied by an indefinite number of electrons but, at most, by two electrons that spin in opposite directions. The orbits are arranged in shells, each shell having a definite level of energy. A shell is complete when it contains the maximum number of electrons compatible with the Pauli Principle. Complete shells consist of 2, 8, 18, etc., electrons. When an inner shell has its quota of electrons, additional electrons must occupy an outer shell. Consequently, instead of falling into the nucleus, the electrons in their lowest energy states will continue to revolve at

a

considerable distance from the nucleus. As already indicated, if there were only electrostatic forces, the elec¬ trons would have long since fallen into their nuclei, neutralizing all electric charges. The universe would be in a state of maximum homotropy. No strong atomic forces would exist and no chemical reactions would take place. The intervention of quantum forces avoids this. It is apparent, then, that the organization of the atom results from the operation of two types of forces, electrostatic and quantum, the electrostatic serving to bring and keep nucleus and electrons together to constitute the atom, the quantum accounting for a motion of electrons which prevents their total annihila¬ tion and the neutralization of all electrical charges. Homotropic and Heterotropic Forces in the Atom

We may now attempt to consider electrostatic and quantum forces in the atom in terms of homotropic and heterotropic trends. Let us hypothesize an atomic system in which only electrostatic forces are active and compare it with a real system which also has active quantum forces. Whereas the fictitious system will rapidly evolve towards a state of maximum homotropy, with annihilation of all charges, this will not occur in the real system. When the two systems have reached final states of equilibrium, the homot¬ ropy of the imaginary system will be greater than that of the real system. If the quantum forces that keep the electrons away from the nucleus in the real atom could be withdrawn, the electrostatic forces acting alone would bring about a state of complete annihilation, thus making available a certain amount of energy that had previously been preserved by the

unaina irom

Digitized by GOOgle

UNIVERSITY OF MICHIGAN

BASIC

CONCEPTS

OF

ORGANIZATION

/

5

quantum forces. In this sense, it is apparent that the electrostatic attraction between nuclei and electrons is of a homotropic character, while quantum forces are heterotropic. %

Fulfillment * of Quantum and Electrostatic Forces

There are diverse consequences from the operation of quantum and electrostatic forces in the atom. The partial fulfillment of the electrostatic forces keeps the nucleus and electrons together in the atom, while quantum forces cease to exist with the establishment of complete electron shells, and have, therefore, been called “saturation forces.” In the atoms of the noble gases, quantum and electrostatic forces are simultaneously fulfilled. As a result, these atoms are inert. They have no physical or chemical activity and their entry into the formation of molecules is explained by the intervention of van der Waal’s cohesion forces. In all other atoms, the electrostatic forces are fulfilled when the number of orbital electrons corresponds to the nuclear charge. However, when this occurs, the electron shells are incomplete and consequently unfulfilled quantum forces are present. When the quantum forces are fulfilled, other electrostatic forces appear. Under these circumstances, in order to complete its outer electron shell, i.e., to fulfill the quantum forces, an atom may borrow or lose one or more electrons. This is achieved with a second atom which, by the ex¬ change, reduces or increases its orbital electrons to fulfill its quantum forces and is left with a number of electrons consistent with a complete outer shell. The fulfillment of quantum forces requires changes that in¬ volve a displacement of electrons outside the atom itself. This exchange of electrons, properly called “electron transfer,” fulfills, to be sure, the quantum forces of the atom. However, as a result of the transfer, the relationship between each nucleus and its orbital electrons is changed, re¬ sulting in covalent ions. Those atoms that have gained by the transfer and have an excess of electrons now have a negative charge while those that have lost electrons have a positive charge. As a result, new electrostatic forces appear which, although confined to the atoms themselves, influence their external behavior, as evidenced by the interaction between atoms. An antagonistic relationship can be conceived between electrostatic and quantum forces in the sense that the fulfillment of one usually leads to appearance of the other. Electron transfer represents only one mechanism for fulfilling the quan•We have unwillingly resorted to this too anthropomorphic term, the use of which has to be excused as didactic license.

Digitized by

Google

unginai Trom

UNIVERSITY OF MICHIGAN

6

/

RESEARCH

IN

PHYSIOPATHOLOOY

turn forces of the atom. Two atoms which do not have sufficient electrons in their external shells to complete the external shells of both can fulfill their quantum forces by sharing some of their electrons. By achieving a complete external shell for each atom, the sharing process satisfies the quantum forces of both atoms. This method of quantum fulfillment through the sharing of electrons also can lead to the appearance of electrostatic forces. If the two atoms are identical, the shared electrons have an inter¬ mediate position and, therefore, do not influence them. As a result, the atoms have their quantum forces fulfilled without inducing new electro¬ static forces. This is the so-called “homopolar bond.” If, however, two atoms are dissimilar energetically, their shared electrons will be located closer to one atom than to the other, the distance being determined by the competitive influence exerted by the atoms upon the shared electrons. At the same time, other electrons will be influenced by the bond, and, as a result, their orbits will be altered to some extent. Weaker electrostatic forces will result and the bond will be intermediary between the ionic and the homopolar. Both kinds of fulfillment of quantum forces—one achieved by transfer, the other by sharing—thus lead to the appearance of new electro¬ static forces in the ions or ionoids. We must repeat here for emphasis that the fulfillment of quantum forces can take place through various avenues, either by loss or gain of electrons, or by sharing which can range from ionic to homopolar. The plurality of possibilities for fulfillment of quantum forces is very important, making it necessary to consider the results of such fulfillment on a statistical basis. The electrostatic forces act between charged ions of opposite signs, or between atoms bound by shared electrons. Through the balance of these electrostatic forces, bound atoms appear and correspond to neutral forma¬ tions, having their electrostatic forces fulfilled. However, it is only with the intervention of suitable quantum forces that the bound atoms can form a new entity, the molecule. Quantum and Electrostatic Forces in Molecules

Alternate operation of electrostatic and quantum forces leads to the organization of atoms into molecules. The quantum forces in the molecules intervene to permit organization of these entities so that the constituents are maintained at proper distances and positions. The result is electro¬ static neutrality. The appearance of new quantum forces that maintain the constituents, through their organized movement, at certain distances and in certain positions, insures not only the establishment but also the stability of the new formations. Besides vibrational movements, other more definite

Google

Original from

UNIVERSITY OF MICHIGAN

BASIC

CONCEPTS

OF

ORGANIZATION

/

7

movements can be recognized in the new molecule. When two or more atoms become associated by shared electron bonds, the shared electrons no longer are confined to one atom but are displaced from their own orbits. Under certain conditions, electrons can travel between two or more atoms, or even surround the molecule as a whole. These movements which corre¬ spond to the intervention of quantum forces give stability to the molecule. The fulfillment of intramolecular quantum forces will affect molecules in a similar way as fulfillment of atomic quantum forces affects atoms. By a process similar to that governing motion of electrons in atoms, motion of entities that enter into the structure of molecules is also controlled. The fulfillment of quantum forces is achieved in various ways. For example, there may be localization of the movement of electrons in the molecule. As the result of relative immobilization of these electrons, electrostatic forces appear in the molecule as a whole. The relatively immobilized electrons can be considered as being related to the molecule as an entity, since they cannot definitely be attributed to any of the constituent atoms. As a result, the molecule becomes electro¬ statically active. The positions of electrons and even of atoms in molecules can be under¬ stood easily by considering events at the molecular level in the same way we considered those at the atom level. The molecule whose electrostatic forces are balanced is neutral. However, it has active quantum forces which govern the position and mobility of the constituents and the relative positions of bound atoms or of certain electrons in the entity. Fulfillment of molecular quantum forces is realized through changes in movement of electrons which lead to loss or gain of one or more electrons, protons, ions or even groups of atoms. This leads to appearance of electrostatic forces and the molecule becomes an active entity. In the molecule, as in the atom, quantum forces can be fulfilled in more ways than one—although one may represent a preferred situation. For this reason, activation of molecules, through changes in mobility of molecular electrons, has to be considered on a statistical basis. The electrostatic coulombian character of an activated molecule is the result of the changes in mobility of the electrons. Positive or negative areas in the molecule develop according to the abundance or dearth of electrons, at these positions. The new electronic arrangements in a molecule can be seen as representing a preparatory step for the molecule to become an active entity in the same way that atoms are activated and become ions. The molecule loses or gains one or more electrons, (or protons, ions or groups of atoms) and becomes electrostatically active, with positive or nega-

Google

UNIVERSITY OF MICHIGAN

8

/

RESEARCH

IN

PHYSIOPATHOLOGY

tive charge, depending upon the nature of the lost or gained entity, and this is the outcome of the fulfillment of the molecular quantum forces. This is illustrated by the following examples concerning the benzene molecule, and the carboxyl and hydroxonium radicals, in which we shall limit our¬ selves to changes produced by quantum and electrostatic forces. In the benzene molecule, which is electrostatically neutral, the electro¬ static positive and negative forces of the constituent atoms are balanced. However, all the electrons are not in fixed positions. The w electrons of the double bonds move around in the molecule. Because the molecule is closed, this movement is circular, thus accounting for the stability of the molecule, recognized in part by the equal reactivity of all its carbon atoms which is encountered under certain conditions and results in the Kekulian forms. The fulfillment of the quantum forces accounts for a kind of relative fixation of these wandering * electrons which is responsible for the other structures of the benzene molecule different from the Kekulian ones. It is this localization of electrons with the capacity to enter into further reactions which results in the activation of the molecule as seen in the resulting Dewar structures which in turn accounts for active centers such as ortho, meta, and para positions. These excited molecules, electrostatically active, can readily take part in chemical reactions. Study of the mobile n electrons in many other molecules allows us to understand their role in providing molecular stability, while their relative localization favors the appearance of electrostatically active centers in the molecule and resulting reactivity. Here again, localization of electrons opens up many possible avenues to activation. The carboxyl and hydroxonium ions represent typical examples of another kind of activation. Inactive carboxyl occurs when the quantum forces cause the electrons to wander continously between the two oxygens of carboxyl. Because of this electronic condition, the H atom seems no longer to be bound to either of the O atoms, but is situated between both; this form corresponds to the electrostatically fulfilled condition. With ful¬ fillment of quantum forces, the wandering electron takes a more fixed posi¬ tion at one or the other oxygen. When this occurs, the H+ ion leaves the carboxyl group, and the carboxyl acquires a negative electrostatic equilib¬ rium, leading to further combining activity. This fulfillment of the quantum forces is responsible not only for the appearance of an activated group of electrostatic character, but also for the existence of two structures, each one with another active oxygen. A similar activation takes place when a molecule acquires an ion, as seen for the hydroxonium ion. Water can, under certain circumstances,

Dig

ed by

Google

UNIVERSITY OF MICHIGAN

BASIC

CONCEPTS

OF

ORGANIZATION

/

9

bind a proton resulting from a hydrogen atom which has lost its electron. This bond is achieved through a valency bridge, and can be regarded as the fulfillment of molecular quantum forces. Different structures can be considered as resulting from the fixation of the hydrogen bridge in different positions in relation to the tetrahedral constitution of the oxygen atom. They help to give this bridge bond its high resistance. Bonding of Molecules

Electrostatic forces in radicals or activated molecules may be further balanced when new bonds are realized between entities with opposite elec¬ trostatic forces. Bonding of molecules having electrostatically excited cen¬ ters may or may not be of chemical nature which is considered to correspond to changes in the structure of the molecules. More often, only a physical bond between molecules takes place, in which case there are no changes in molecular structure. Both types of bonding result in fulfill¬ ment of the electrostatic forces through a balanced neutralization, but bond¬ ing alone is not sufficient to establish a new entity. A new entity, with structural and functional individuality, apparently is realized only when quantum forces appear and establish definite relationships between the bonded constituents* molecules, placing them in certain positions and organ¬ izing their movements. The holistic concept emphasizes the difference between molecules or radicals bound only by the fulfillment of their electro¬ static forces of general coulombian character, and the new entities result¬ ing from the appearance of specific quantum forces proper to them. Here again, then, at the molecular as at the atomic level, progress in organization is achieved by alternate operation of electrostatic and quantum forces. Polymolecular Formations •

When an electrostatically active molecule or radical binds an electron, ion or even a small radical, the resulting entity is still considered a simple molecule. The group resulting from the bonding of several polyatomic radicals is a complex molecule. Like simple molecules, complex molecules also can group together and the bonding of several leads to still more complex formations, the macromolecules. In turn, macromolecules also can be grouped and the bonding of two or more produces polymolecular for¬ mation. Thus, organization progresses from simple molecules to polymolec¬ ular formations, first through the grouping together of similar entities. A •All three terms—macromolecules, polymolecules and complex molecules—are chosen only for didactic convenience.

Digitized b)

Google

UNIVERSITY OF MICHIGAN

10

/

RESEARCH

IN

PHYSIOPATHOLOOY

new entity appears when one of these groups binds a respective secondary part. Micelles

A distinctive type of new entity results from the bonding of molecular formations with simpler constituents, such as ions or ionized molecules. To this type of entity we have applied the name of “micelle.” • Poly molecules, macromolecules, complex molecules or even simple molecules can form the principal part of these micellar entities. According to the above definition, micelles are entities formed by the binding of molecules, as principal units, to ionized molecules or ions, as secondary units. The latter originally were considered to be “impurities” until Duclay showed their important role in establishing specific entities. According to our concept, micelles are produced when grouped molecules and active impurities become bonded as the result of reciprocal balance of electrostatic forces and the alternate operation of electrostatic and quantum forces, seen for atoms and molecules, applies again. Fulfillment of electro¬ static forces leads to appearance of quantum forces, this time proper to the micelles. The quantum forces maintain the micelle constituents in proper positions and govern their movements, described as vibratory for these entities. The operation of the quantum forces, together with fulfillment of the electrostatic forces, accounts for the stability of micelles. The micellar quantum forces also can be fulfilled, leading to the appear¬ ance of unequal distributions of micelle constituents. The micelle then passes from relatively neutral to an electrostatically active form which can enter into further bonds, and it is primarily in further bondage that micelles appear in a reticular aspect. In an overall view of the development of organization, from atoms to micelles, the relatively simple pattern of alternating operation of electro¬ static and quantum forces can be recognized. The regularity of the pattern allows us to consider it as fundamental to the progress of organization. We have tried to go further and to recognize the existence of this same simple organizational system for formations below the atom and above the mi¬ celles. We tentatively conceived of subatomic formations being organized in the same manner, i.e., by alternate operation of electrostatic and quantum forces. We will not go into this study here as it would lead us too far from • It is to this type of structure that we apply the term micelle, as distinguished from various other meanings found in the literature.

Google

Original from

UNIVERSITY OF MICHIGAN

BASIC

CONCEPTS

OF

ORGANIZATION

/

II

the subject of this presentation. An outline of this subject is presented in Note 1. Organization of Motion as Heterotropic Achievement

An interesting aspect of the concept presented above is the influence of homotropic and heterotropic forces upon the motion of particles within the organizational framework. At-random mobility must be considered to be an attribute of entities free of any constraint, and thus corresponding to a homotropic state. Any change toward constraint, leading to a degree of immobilization, must be considered a heterotropic effect. The systematized mobility produced by quantum forces, which appears to prevent annihila¬ tion of opposing charges, accounts for the relative immobilization. While mobility itself is an homotropic attribute, its systematization is heterotropic. The correlation of mobility with homotropy, and of fixation with heterotropy, appears basic. The process of uniformization which corre¬ sponds to homotropy appears to be possible only in the presence of a maximum of free mobility. The heterotropic systematization of movement can be seen at various levels of organization. Electrons in movement in the atom differ from electrons in movement in the environment through a sys¬ tematization of their mobility, as they are constrained to follow definite patterns. The relative fixation of certain electrons—for instance, shared electrons—following the fulfillment of quantum forces also marks a further heterotropic influence. This also applies to radicals such as the carboxyl. In the formation of — CS

the movement of electrons, in itself, is

homotropic, while the limitation of movement between the two oxygens is an heterotropic effect. With the electron fixed in one position, bound to only one oxygen, a further step in immobilization is achieved and represents a heterotropic factor. In more complex molecules, such as unsaturated fatty acids, for example, the tendency of the electrons to wander is related to homotropy, while their restriction to the molecule or even to certain areas of the molecule represents an heterotropic effect. This also applies to micelles, where the water molecules and impurities have a certain degree of mobility. This mobility must be considered to be a vestige of the move¬ ment of free water molecules, with a high mobility considered as a homopolar effect at this level. The retention of water or other molecules in the micelle may be considered as a heterotropic effect. And their further fixa¬ tion, as in the activated micelle, is a further heterotropic effect. Organization, which results from the alternate operation of electrostatic

onama from

Digitized by GOOgle

UNIVERSITY OF MICHIGAN

12

/

RESEARCH

IN

P HYSIO P ATH OL OGY

coulombian homotropic and organizational heterotropic tendencies, leads to the realization not merely of stable configurations but, more significantly, to entities capable of reactivity, and consequently able to respond actively to the various changes of the environment. The fact that fulfillment of quantum forces causes appearance of new electrostatic forces, which will be further neutralized, leads to the progress of organization to ever-higher levels. At each step of organization, however, another characteristic can be recognized. It results, in part, from the fact that progress toward higher entities is accomplished by an increase in complexity rather than only in size. The increase in the positive charge of nuclei in atoms, for instance, brings about a parallel increase in the number of surrounding electrons, but this goes on only up to a certain point. Actually, the size of the atoms is limited by the size of the nucleus which, in turn, is limited by the quantum forces able to insure stability for the nucleus. Nuclei become unstable when they contain too many protons. Levels, Entities and Constituent Parts

As already noted, we defined an entity through its structural and func¬ tional individuality. We used the term “lever* to indicate a conceptual grouping of entities having the same basic constitution, such as, respectively, nuclei, atoms, molecules, micelles, etc. We have used the term “part** to define an entity when it contributes to the formation of another entity. Nuclei and electrons are parts that form an atom. Molecules are parts when they are bound through electrostatic and quantum forces to form micellar entities. In progressive organization, each new entity thus is composed of parts which are entities from the level immediately below, and the new entity itself serves as a part for the im¬ mediately superior entity. We call this relationship “hierarchic,** one entity being inferior to that which it forms and superior to those which have formed it. So conceived, each new organizational entity can be identified not only through the nature of the parts forming it and the manner in which they are bound, but also through its level in the hierarchic succession. We have seen that most of the entities are made up of dissimilar parts. Analysis of what happens when an entity is formed has shown that the process is complex. In order for an entity to act as a part in a higher level, it must first pass through an activated stage. Activation opens up many opportunities, a plurality of possible formations. So does another process, an immediate consequence of activation. Almost continuously, several similar entities are seen to join together in a kind of “common grouping,”

Digitized

Google

i lnnmAi

UNIVERSITY OF MICHIGAN

BASIC

CONCEPTS

OF

ORGANIZATION

/

13

adding further to the multiple possibilities of new entities. The multiplicity of possiblities at each step in organization explains the exponential increase in the number and complexity of the entities, resulting from the hierarchic pattern of their formation. According to the holistic approach, an entity exists only through its own qualities. It must have characteristics other than those of its constitu¬ ents. It is the relationship between the constituents, in the new entity, largely resulting from the operation of quantum forces, that characterize the entity. Principal and Secondary Parts

As noted, entities at progressive levels of organization are formed of dissimilar parts. These parts do not have equally important roles. There is a “principal” part which is characteristic for a given level. There are “sec¬ ondary” parts that are nonspecific for the level, the same ones can serve at different levels. The secondary part for a hierarchic entity often is an entity of a far lower level. (Fig. 1)

Principal Parts First Entities •

Secondary Parts of the Second Entity

Second Entities f the Third Entity Third Entities f the Fourth Entity Fourth Entity—

Fig. 1. The hierarchic organization. In the organization in general, the different entities appear interrelated according to a characteristic hierarchic pattern. Each en¬ tity is formed by a principal and a secondary part. An entity is hierarchically “su¬ perior” to the entities which form its principal part and “inferior” to those in the formation of which principal part it enters.

Secondary parts have important characteristics in common. These be¬ come especially evident when lower level entities are examined. At levels below the atom, secondary parts for all entities are electrons. It is of interest to observe that in higher entities as well, such as molecules or micelles, all secondary parts have a negative electrical charge.

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

14

/

RESEARCH

IN

PHYSIOPATHOLOGY

Also characteristic of secondary parts is their derivation directly from the environment in which the entities of which they are components, appear. This is clear for many crystals, where water molecules represent the added secondary part. This water of crystallization is not free between the ions but bound to them. Water appears indispensable to crystal formation, since its loss results in disintegration. Water can be considered to play a second¬ ary part. Similarly, in some crystals such as gold, some electrons wander between the atoms while others are concentrated in certain regions. (Brillouin) These electrons represent a secondary part in these crystals as do water molecules in others. Water and electrons can be related to the en¬ vironment from which they derive. Derivation of the secondary part from the environment appears to be even clearer at the micellar level. In the case of the gelatinous precipitate obtained by coagulating a colloidal solution, a part of the environment in which the gel is precipitated enters into the formation of the new micelle. For example, the micelle of colloidal copper ferrocyanate contains potas¬ sium ferrocyanate as a secondary part for each principal part of copper ferrocyanate. Micelles of ferric hydrate, obtained by the hydrolysis of a boiling iron perchloride solution, provide another example. Besides the Fe208, molecules from the Fe«Cla solution used in the preparation enter into the formation of this hydrosol. The role of the negatively charged con¬ stituents becomes apparent when a part of the cation of this secondary part is removed from the intermicellar fluid and the hydrosol still persists. It is only when the chloride content becomes too low that coagulation results. The molecules of potassium ferrocyanate or iron perchloride, once con¬ sidered to be impurities, must be looked upon as secondary parts of these micelle entities. Derived from the environment, they enter into the forma¬ tion of the micelles, especially through their negative electrostatic character. This concept becomes of even greater importance when entities are considered in relation to the constantly changing environment. The electro¬ static balance between entity and environment realized at any given time cannot be considered to be permanent because of the changes which occur in the environment as it travels toward ultimate total homotropy. As a working hypothesis, it can be assumed that the relationship between entity and environment would change as the latter moves toward total homotropy. It can be assumed, too, that as hierarchic organization develops in time, secondary parts from the environment would differ for different entities. Changes in environment would provide evidence that these secondary parts are related more closely to the environment as it existed in the past when

Google

UNIVERSITY OF MICHIGAN

BASIC

CONCEPTS

OF

ORGANIZATION

/

15

these entities are assumed to have appeared. We will see below how im¬ portant this is for the more complex entities of higher levels. In the role played by secondary parts in progressive organization, the changes in their mobility are of special significance. We have already seen that in hierarchic entities the secondary parts are simpler units than the principal parts, a factor which facilitates their mobility. The mobility can be related to the fact that these secondary parts are derived from the environment where they are mobile, with their motion not systematized. The intervention of quantum and quantum-like forces, which help to create new entities, can be seen as a kind of organization of the relative mobility of the secondary parts. It is the systematization of their movement which prevents complete annihilation of electrostatic forces present. The rela¬ tionship between secondary parts and environment thus explains the character of the mobility encountered throughout hierarchic organization. It must be emphasized here that, because of the electrostatic nature of the bond between principal part and secondary parts, a principal part is capable of entering into the formation of more than one specific type of entity. Similarly, fulfillment of quantum forces can lead to more than one type of structure. However, of the many possible new entities, or struc¬ tures, only a few will fulfill the requirements for developing a still higher organization, i.e. will be capable of acting as principal part in a new en¬ tity. Some remain at their original level without progressing, even after being bound to other entities. Even many of those which have some capa¬ bility for higher organization can go only one or two steps. Only a very few will continue all the way up. In other terms, only a few will be able to utilize new quantum forces in order to realize new entities. While vari¬ ous bonds and structures offer a large variety of possible new entities, it is the entity with a capacity to adequately resist the effects of the changing environment which will take part in progressive organization. In considering the forces which intervene in progressive hierarchic organization, one has to consider the free energy available in the environ¬ ment. The immense amount of energy received from the sun represents a type of heterotropic energy which can intervene in organization. We will see that this is easily recognized for higher entities. The ability of certain entities to develop may be related to their peculiar ability to utilize hetero¬ tropic forces, most of them of solar origin. The less successful disappear or remain at lower levels.

Digitized b

Google

UNIVERSITY OF MICHIGAN

16

/

RESEARCH

IN

P H YSIO P ATH OLOG Y

The Organized Boundary

We have seen that an entity achieved through systematization of the movements of its components acquires a boundary between itself and the environment as a result of this restricted movement. The boundary does much more than delimit the entity and constitute a barrier between it and the environment. The electrons of the outermost shell form the boundary of the atom, for example. It is through them that the atom realizes its rela¬ tionship with the environment. Chemical reaction is largely limited to this boundary. In the atom, where the nucleus is the principal part, and the electrons are the secondary part, it is evident that it is the organized move¬ ment of the electrons that provides the boundary. The form and organiza¬ tion of electronic shells, and specifically of the boundary shell of an atom, are results of quantum forces. The environmental nature of the secondary parts and their buffering role make them of great importance in complex boundary formation. Theoretically, hierarchic progress may be considered to depend upon the development of secondary parts which allow increas¬ ingly complex boundary formations. This explains the importance we attach to the study of boundary formation in higher entities. To summarize the above concept of organization, the different entities can be integrated into a hierarchic organizational pattern which depends upon alternate operation of the two fundamental forces, electrostatic of coulombian nature, and quantum of organizational nature. Entities can be identified by the nature of the inferior entities that act as constituent parts and the relationship between constituents as principal and secondary parts. While the principal part is formed by an hierarchically developed entity, the secondary part is a second entity from the environment. The incorpora¬ tion of a part of the environment into a new entity corresponds to a sys¬ tematization of its motion. And it is through the organized motion that appears a boundary formation which marks the realization of a new hier¬ archic entity. This concept of organization has made it possible to understand the relationship of the series of entities that compose the biological realm.

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

CHAPTER

BIOLOGICAL ENTITIES

w™ the concept

of hierarchic organization, it becomes possible to

gain a new insight into, and understanding of, the biological realm. In the classical view, just as simple substances in nature are conceived of as being formed by molecules and atoms, biologically complex organ¬ isms are considered to be composed of cells as fundamental entities. In arriving at complex organisms, however, it is granted that organization has followed a definite pattern. At first glance, it is apparent that cells are grouped in morphologically regular ways to form tissues. Similarly, tissues are grouped to form organs and these in turn compose the organism. In this classical systematization, a complex individual would appear to be the result of a grouping of cells, tissues and organs, bound together in what has been described as an harmonious morphological relationship. In our study of organization of the biological realm, we have empha¬ sized the individualization of both conceptual and material entities. In some cases, entities have been simple to identify because they

are easily

separable morphologically. Where morphological separation has not been immediately evident, other criteria—such as structural and functional properties—have been used for identification. Besides playing its part in organization, each entity has its own individuality, and consequendy can be recognized holistically as a well-defined unity. Starting with chromomeres, the entity status is easily accepted because, in addition to clear morpho¬ logical and functional properties, there is a degree of independent indi¬ viduality. Following up, chromonemata, chromosomes, nuclei are other entities. The study of the organization of biological entities has shown, how¬ ever, that in all cases there is a specific pattern of interrelationship which is more complex than the classically accepted pattern. In the simplest micro17

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

18

/

RESEARCH

IN

P HYSIOP ATHOLOG Y

scopically identified entities, it could be seen that a series of chromomeres are bound together through a special fibrillar formation, which stains differ¬ ently from the chromomeres, to produce the chromonemata (1, 2), which can be considered holistically as a new entity. Two or four chromonematas (3 ), together with the chromosomal sap, form the chromosome as a new en¬ tity. Similarly, several chromosomes together with another part—this time represented by the nuclear sap and the proper nuclear membrane—form a nucleus. In turn, the nucleus, plus protoplasmic formations, cytoplasm and the cellular membrane, form the cell. Even superficial analysis indicates a common fundamental pattern in the organizational changes taking place for entities ranging from chromomeres to cells. Because of this pattern, these entities can be considered to be “hierarchically” interrelated. One entity is hierarchically “superior” to the entities which form it and “in¬ ferior” to those it will itself help form. Two immediately interrelated enti¬ ties thus are hierarchically superior and inferior, respectively, just as in organization in other realms. (Fig. 1) Analysis of the progression of organization from simple to more com¬ plex entities permits us to recognize other characteristics of the fundamental pattern. In order to form a hierarchically superior entity, several similar en¬ tities first join to form a group. It is the group which then will bind other constituents to bring into existence a new, hierarchically superior, bio¬ logical entity. Thus, the chromomeres as a group join with a fibrillar forma¬ tion to produce chromonemata; chromonemata join with chromosomal sap to form chromosomes. Groups of chromosomes plus nuclear sap form the nuclei. It has appeared evident that the parts which are bound to form each hierarchic entity do not play equal roles. In each case, the principal part is the one which is composed of similar entities acting as a group; the other part is the secondary. Figure 2 offers a graphic representation of hierarchic organization from chromomeres to cells. In all entities, mentioned above, there is the same relationship between principal and secondary parts. The secondary surrounds the principal part. The morphological relationship has helped us to apply to those entities the hypothesis discussed previously concerning the mechanism through which hierarchic progression has taken place in nature. According to the hypothe¬ sis, several similar entities would first associate and form a group. In a second step, the group would tend to maintain around it a small portion of its immediate environment. From this portion of the environment would come the secondary part for the next superior hierarchic entity. With a boundary formation, separating this minute part from the rest of the en¬ vironment, the new entity would be established. Such a process could oc-

t!zedb> Google

onnina rrom

UNIVERSITY OF MICHIGAN

BIOLOGICAL

ENTITIES

/

19

cur, although rarely, with a single biological entity serving as principal part Usually, several entities grouped together would be needed. This pattern explains why the secondary part can be conceived of as a part of the envi¬ ronment retained around the principal part, and why the establishment of a new and higher entity can be considered to occur only when this sec¬ ondary part is detached from the rest of the environment and separated from it through the intervention of a boundary formation.

Added Secondary Formations

Entities

Fibrillar material Chrooosomial sap Nuclear sap Cytoplasma

Fio. 2. The hierarchic relationship in the organization of morphological entities below cells. For each entity its principal part is recognized as being made by a grouping of entities hierarchically inferior to it. The secondary part which corresponds to a kind of environment for the principal part usually surrounds the principal part.

Having recognized this pattern of organization for lower entities, we went on to determine whether it remains the same for higher entities. It could be seen that groups of cells, along with interstitial formations and fluids around them serving as secondary part, create the tissue as a new hierarchically superior entity. Indeed, a proper boundary formation mor¬ phologically limits and conceptually defines the new entity. The interstitial fluids are separated by a continuous endothelium limiting the lymphatic spaces as a system closed toward the intercellular spaces. Under these cir¬ cumstances, the lymphatic endothelium serves as the corresponding bound¬ ary formation that limits the tissue entity. Several tissues grouped together, playing the role of the principal part, bind the lymph, as secondary part, to form the organ, as a new hierarchic entity. Lymphatic vessels and connective tissues represent the organ’s boundary formations. Further-

Digitized by

Goo

UNIVERSITY OF MICHIGAN

20

/

RESEARCH

IN

PHYSIOPATHOLOO Y

more, organs grouped together, with blood as secondary part, form the entity called the organism. (Fig. 3) Does the same pattern apply for entities hierarchically inferior to chromomeres? For these lower entities, morphological information to define the relationship between principal and secondary parts is unavailable for

Entity

Added Secondary Formations

Fio. 3. The oganization above the cells. The hierarchic pattern of the organization in general is recognized also in the organization above the cells. Tissues, organs, organism are seen to represent hierarchic entities, each one being made by a principal part formed by the grouping of entities hierarchically immediately inferior to it. The principal part is bound to a secondary part characteristic for each entity. This sec¬ ondary part would correspond to the proper environment in which the entities form¬ ing the principal part, have evolved.

the moment. Until electron microscopy and other means provide such data, we are obliged to find other criteria to indicate which, in these hier¬ archic entities, is principal and which secondary part. We have considered electrical characteristics of the constituents as criteria for identifying their role in the hierarchic organization of biological entities below chromomeres. Biological Realm

Before going further in trying to analyze submorphologic hierarchic entities, one problem was to establish the limits of the biological realm

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

BIOLOGICAL

ENTITIES

/

21

itself. The question was, how far below the morphological formations could we go and still have entities which can be regarded as biological. With the progress of science, criteria previously used to define life have become out¬ moded. A separation line between the animate and inanimate no longer can be drawn. With the study of the properties of viruses, it appeared impossible to maintain the last vestige of the old vitalistic concept. Accord¬ ing to most of the classical criteria, viruses would represent animate enti¬ ties since they are able to multiply and conserve a strict identity. However, they also form salts, are crystallized, broken down, and then reconstructed in the same or another order. If the viruses are accepted as “borderline” entities, as proposed, then the concept of animate and inanimate can no longer be sustained. Although the animate and inanimate cannot be distinguished in terms of a specific property, we cannot totally overlook the fact that an important group of entities appear quite different from others in nature. As animals and plants are different from stones, even without any vitalistic concept, we are obliged not only to recognize the difference, but also to try to establish where the difference lies. To conform to reality, we have applied the term “biological” to a group of entities, but we have given the term a new meaning. Just as organic chemistry is considered—whether correctly or not—to comprise certain combinations of carbon, we consider the biological realm to comprise entities hierarchically developed from a specific chemical radi¬ cal. This basic radical includes nitrogen and carbon atoms bound together to form the N-C-N-C group. According to this concept, starting from the basic nitrogen-carbon formation, an entire series of entities has been de¬ veloped through hierarchic organization. Together they form the realm to which the term “biological” can be applied. The N-C-N-C group, through combination with hydrogen, would result in radicals with a strong alkaline property; that is, with strong positive electrical character. Some of these N-C-N-C groups take part in the forma¬ tion of nitrogenous bases, pyrimidines and purines, while some, by acting as principal part and binding various amino acid radicals would, with the necessary electrons, build up a new group of entities, arginine and histidine as alkaline amino acids. These can be considered, hierarchically, to be the immediate superiors of the N-C-N-C group and thus to represent the first biological molecules. The alkaline positive character of these molecules is noteworthy. Following the hierarchic pattern described above, several such alkaline amino acids linked together to a series of entities of the same level (simple amino acids) will form new groups that are still electrically positive:

Google

UNIVERSITY OF MICHIGAN

22

/

RESEARCH

IN

P HY S IO P A TH OL OO Y

the alkaline histones. In a new step, these histones will act as principal part to produce nuclear entities. (Fig. 4) Principal parts, by binding different secondary parts, can form not one but many new and different entities. More than one hierarchic line can be identified. An especially important line results when histones bind one or more entities of the nucleic acid group, to form nucleo-proteins. Other histones can bind various other secondary parts such as carbohydrates or lipids and, in so doing, form different biological entities. Some of these

Added Secondary

Principal

Formations N-C-N-C group Alkaline amjrjo

Amino acid group

Histones

amino acids

Deoxvribo———1 nufcleoproteins

Deoxyribonucleic add

Genes

Nucleoproteins and other sec. entities

Fio. 4. The organization of the submorphological entities of the biological realm. The same hierarchic general pattern, with principal and secondary parts is recognized. Starting with the positive CNCN group, each entity has its principal part made by the grouping of immediately inferior entities bound to secondary parts, generally more electronegative.

entities can continue their hierarchic development. Nucleo-proteins can have ribose or deoxyribose and consequently form more complex nucleoproteins. Through all hierarchic achievement, it can be seen that new lines are formed when groups of hierarchically lower entities, acting as principal organized part, bind different secondary parts, all more negative than the principal part. Theoretically, this would result in a series of entities all at the same level, i.e. entities with similar principal parts but having different secondary parts. Some would go on to develop superior hierarchic entities, others would evolve no further. Different entities of the the same level can be grouped together in vari¬ ous ways to form a variety of principal parts. Always the group must be made up of entities of the same level. This requirement has been seen to be general at all hierarchic levels. Since differences can exist between the

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

BIOLOGICAL

ENTITIES

/

23

constituents forming the principal part for a new entity, the predominance of one or another constituent will make entities at the same level differ. This mechanism of differentiation through the constitution of the principal part has been extremely important throughout the biological realm. Nucleolus

The concept that plural groupings can enter into the principal part of the nucleus puts the role of the nucleolus in a new light. It was accepted for a long time that the nucleolus represents only the reserve material necessary for metabolism of the nucleus. The strong positive electrical character of the nucleus, as recognized through its rather alkaline reaction, would give it roles more important than that of the other constituents. According to a work hypothesis which we advance, successive nucleolar formations would represent the principal parts of hierarchic organization below the nucleus level. In chromonemata, chromosome and nucleus, the parts corresponding to the nucleolus can be recognized. These formations are grouped together with genes to form the principal part of the chro¬ monemata. Similarly, chromatine formations representing entities of the same level as the respective nucleolar formations, will form together the groups characterizing the principal part of chromosomes. In the nucleus, the nucleolus is joining the other formations to form its principal part. Protoplasmatic Formations

In the cell, a hierarchically superior entity, a similar condition also appears to persist. The protoplasmatic formations with ribo-nucleic acid can be conceived as representing entities of a nuclear level, that is, a level similar to that of the nucleus. Together with the nucleus they would form the group corresponding to the cell. This kind of evolution of entities in relatively separate parallel lines, with their further grouping together to form principal parts for new entities, is part of the typical pattern of organization especially evident in the biological realm. Boundary Formations

We have mentioned that groupings of several entities would not be sufficient to form a new entity so long as the secondary environmental part is not isolated from the medium from which it originates. Consequently, the new entity appears only when a distinct boundary formation is formed. Progressive hierarchic development is dependent upon the appearance of such boundary formations. For the first biological entities, the radicals, the boundary seems to be more an energetic property than a morphologically

Digitized by

Goo

UNIVERSITY OF MICHIGAN

24

/

RESEARCH

IN

PHY SIOPATHOLOOY

organized formation. For the molecules, it can be considered to consist of molecular surface forces, recognized as the van der Waals cohesion forces. A similar but more apparent boundary formation can be found in higher molecular complexes, especially the micelles. The molecular arrangement at the surface of micelles separates them from their environment and conse¬ quently insures their identity. In the case of morphologically identifiable enti¬ ties, of course, boundary formations can be easily recognized. Chromomeres are well-defined and separated from the chromosomal sap. The chromo¬ somes, in turn, show a real membrane just as the nucleus and the cell do. The next higher entity, the tissue, is bounded by the endothelial cellular layer, separating the interstitial formations from the lymphatic spaces. Usu¬ ally the boundary of organs which have tissues as principal and lymph as secondary parts is represented by organized blood vessels. As far as the organism is concerned, the mucous membranes and skin are boundary formations. (Fig. 5) Hierarchic Interrelationship Viewed as a heterotropic effect, hierarchic organization can be con¬ sidered to be a method of conserving existing entities as such, in spite of changes occurring in the environment. Teleologically speaking, by entering into the formation of a new and superior entity through the system of hierarchic organization, each entity, in fact, protects its own individuality. The hierarchic organization makes it possible for each entity to continue to live in a medium which corresponds to its own environment. The con¬ stituents of the secondary part in the new entity are chosen to correspond to the environment in which the principal part of the entity has existed. The successive secondary parts, added during the hierarchic development, act as multiple protective buffers for the first entities, thus insuring their unaltered conservation in spite of continuous changes in the environment brought about by increasing homotropy. Phylogenetic Development Hierarchic organization, when related to time, would appear to corre¬ spond to evolution. The concept of ontogenesis reproducing phylogenesis, appears in a new light when analyzed in accordance with hierarchic or¬ ganization.

The parallelism between actual hierarchic organization and

hierarchic phylogenetic and ontogenetic development greatly helps to in¬ crease understanding of many principal problems of biology. In accordance with the concept of hierarchic organization, when a new level is realized through the binding of entities from a lower level, as prin-

Digitrzed by

Goo

UNIVERSITY OF MICHIGAN

BIOLOGICAL

ENTITIES

/

25

cipal part, to different secondary parts, several outcomes are possible. Some of the new entities are unable to continue to exist and disappear. Of the others, some are relatively well balanced entities and consequently can

EntiV

Boundary formation

Fig. 5. The boundary formation in the hierarchic organization of the biological realm. A proper boundary formation delimits each entity, insuring thus its individuality. It is by separating each time the secondary part from the rest of the environment that the boundary formations have permitted the progressive development of the hier¬ archic organization. The boundary formation governs the relationship between the entity and its environment.

persist. But with further changes in the environment, some of these entities disappear. Even among those that remain, some do not represent fully satisfactory solutions and further hierarchic development is necessary to insure their persistence. They must evolve further to correspond to the

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

26

/

RESEARCH

IN

PHYSIOPATHOLOOY

new unfavorable external conditions. This has led to the development of the complex entities present today in nature. The multiple entity possibilities at each level have resulted in a wide variety not only of entities which, with further evolution, could produce higher complexes, but also of others which have ended their evolution at lower levels. So the existence of many varied entities appears to be the result of the existence of multiple solutions for the same problems which have been part of the mechanism of hierarchic evolution. From this viewpoint, existing independent entities can be recognized as corresponding to the different levels of hierarchic organization. Viruses can be considered to be at the same level as genes or even the entities immediately below genes; the microbes at the same level as the nuclei; monocellular organisms at the level of cells, etc. Furthermore, in each independent organism, from simple to most complicated, the same pro¬ gression in organization of successive hierarchic entities can be seen, start¬ ing with the simplest biological entities and continuing until the level at which the entity has actually stopped its hierarchic evolution. In a further step, having arrived at the concept that the secondary part of each entity corresponds to the kind of environment in which the entity found itself at the time of its phylogenetic appearance, we tried to see what information about these environments could be obtained through study of the secondary parts. The first biological entities, the alkaline amino acids, could have ap¬ peared in an atmosphere rich in ammonia, water and methane. Experi¬ mentally, electrical discharges through mixtures of these materials have induced the appearance of amino acids. It appears plausible that such an environment could have existed around volcanoes in times when the earth’s atmosphere was formed by ammonia. With steam formed by the heat of the volcano, with methane resulting from the interactions of erupted me¬ tallic hydrocarbons with water, and with lightning so frequent around volcanoes in eruption, the necessary conditions for synthesis of amino acids may have been present. The simple amino acid molecules which would have resulted could have constituted a group needed for hierarchic develop¬ ment. Out of a series of such amino acids, some could have bound the group N-C-N-C which also could have been synthesized under the influ¬ ence exerted by radioactive elements or radiation. (Note 1) Additional information concerning the constituents of secondary parts which enter into the development of all the subnuclear entities is meager. Simple amino acids or urea are present in the chromosomial and nuclear sap which are practically free from K and Na. We could thus consider

Google

UNIVERSITY OF MICHIGAN

BIOLOGICAL

ENTITIES

/

27

ammonium as the predominant cation for all hierarchic entities up to the nucleus. This would accord with geological data concerning a primitive atmosphere in which ammonia was predominant at the time when the first biological entities would have appeared. We can then, tentatively, in view of this cation common to all, classify the hierarchic entities below the nucleus in what we will call “the nuclear compartment.” In the same way, we analyzed the composition of cytoplasm, with the thought that it could provide information about the constitution of a second environment in the evolution of biological entities. The principal cation of cytoplasm is potassium which also represents the principal cation of the earth’s crust. Curiously enough, potassium and the other constituents could oe found in the same relative proportions in the earth’s crust as in cyto¬ plasm, (Note 2) a fact which seems to confirm the hypothesis that mud, humid earth crust, represented the environment in which entities at nuclear levels lived. The cytoplasm conserved this constitution, with potassium as principal cation, when it was separated from the environment to become the secondary part which, with the nucleus, formed the cell as the next superior hierarchic entity. The cell by itself, represents a new compartment with potassium as principal cation. It is only for the animal cell that the environment seems to have changed again. This time the new environment was the sea. When several cells joined together to organize tissue as a new entity, they had to main¬ tain their environment, now represented by the sea. The hierarchic entities above the animal cell show sodium as principal cation in their secondary parts, thus indicating that when they were organized the sea was their environment. This characteristic allows us to group together animal hier¬ archic entities above cells to form a new compartment, the metazoic, with sodium as the principal cation. With passage from marine to terrestrial life, air is found as the new environment. Not integrated as a new secondary part, without a separating boundary formation, the part of the environment kept in the respiratory apparatus does not enter however, into the formation of a new entity. Only the presence of air in the bones of birds can be seen as such integration. A certain fundamental further development, in the same direction can be seen in animals as well as in humans, in the area of social life. (Note 3) Division of complex hierarchic organization into compartments appears to be relatively simple. There are changes in the principal cation from compartment to compartment which correspond to similar fundamental changes in the environment through which the organism passed during its phylogenetic evolution—from volcano to mud, to sea, to the surface of

Dig

by Google

UNIVERSITY OF MICHIGAN

28

/

RESEARCH

IN

PHYSIOPATHOLOOY

the earth. We tried similarly, to correlate other elements in the periodic chart with hierarchic compartments. The results will be presented in detail later. For the moment, it can be stated that elements correlated to dif¬ ferent environments are also found in the different compartments corre¬ sponding to these environments. For example, Mg like Na represent an element of the metazoic compartment and of the sea where this compart¬ ment was phylogenetically organized. Fe, Cr, Ni, Zn, Ca, Mn, Co, As, and Se which fall into the cellular compartment, represent characteristic con¬ stituents of the earth’s crust. Constants

The concept that matter in general is the expression of the heterotropic trend permits us to explain further some of its characteristics which have been of great importance in biological development. Heterotropy can be seen working to maintain existing entities as long as possible, to conserve their characteristic properties in spite of changes in the environment. Het¬ erotropy could result in unchanged values which would appear as con¬ stants of an entity and would indeed identify the entity. It is hierarchic organization which would tend to permit conservation of constants. Each biological entity—just as any entity in nature—can ultimately be defined by the series of characteristic properties which it is able to conserve. Constancy is the criterion which permits us to judge the impor¬ tance of a property to an entity. The longer a property is kept constant despite environmental changes, the greater its fundamental importance to the entity. The progressive addition of secondary parts through hierarchic organization represents an effective means of preserving constants of the lower entities. New properties, added with the formation of each new hierarchic entity, represented new constants. This explains why considering the constants, it can be seen that those incorporated in the lower entities are the best conserved. The higher a constant in the organizational hier¬ archy, the less well-preserved it will be. The idea that constants correspond to the character of the environ¬ ments through which the individual has phylogenetically passed, and that they are conserved through hierarchic organization, permits us to try to extend our understanding of conditions present in past environments. Cations and even anions would represent only one type (apparently the most important) of the constants maintained through hierarchical organ¬ ization. Other constants, correctly interpreted, would indicate in what direction we must search for conditions which prevailed in the environ-

Google

Original from

UNIVERSITY OF MICHIGAN

BIOLOGICAL

ENTITIES

/

29

ment when the respective hierarchic entities that make up a given organ¬ ism were established during phylogenetic development. As examples, let us consider the conservation of salinity and tempera¬ ture as constants. Values for salinity of the metazoic compartment and of the blood and values for temperature have been seen to be constants char¬ acterizing species. Differences between these constants in different species show a succession conforming with paleontological data. In the interpreta¬ tion given by Rene Quinton, constants would indicate the times when various species originally appeared in nature. According to our concept of hierarchic organization, these constants may be interpreted otherwise. They would not indicate the moment when the lowest entities of the respective species were formed, but rather the time in the development of these species when the hierarchic entities capa¬ ble of conserving the respective constants appeared. In other words, they would not indicate the earliest moments of appearance of the first entities which later developed to form the respective species, but would indicate a relatively late moment in the creation of the metazoic entity which has appeared able to conserve, as its own constant, this specific attribute of the environment. In the case of salinity, this would correspond to the constitu¬ tion of the metazoic entity itself which has retained the composition of the early sea in its intercellular fluids. As far as temperature is concerned, the entity which would appear able to conserve it has to be regarded as much more complex and even to be related to the appearance of systems of organs which are sufficiently sensitive to changes in temperature and which also possess the means of insuring constancy for temperature. The conservation of different elements in different compartments ap¬ pears to be characteristic. In order to maintain its constants for elements the entity has to oppose their uncontrolled circulation. The role of hier¬ archic entities in conserving ancestral conditions would explain why an entity would have to oppose particularly the penetration of the constituents which characterize the succeeding environments. This has appeared evident for the cations. The boundary formations which have to play the principal role in the creation of each entity must also insure its identity by barring uncontrolled penetration of elements characterizing the new environments. Invasion by such elements would correspond to an abnormal event which must be corrected. If the invasion progressed beyond a certain limit, it would create a condition incompatible with further existence of the entity.

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

30

/

RESEARCH

IN

PHYSIOPATHOLOGY

Water Circulation The passage of complex organized animals into the new environment of terrestrial life brings to the fore the problem of the place of water in hierarchic systematization. It appears to us an acceptable concept that water does not circulate freely in the organism. Its appearance in hierarchic entities can be understood if, as we did for the other constituents, we relate water to its place in the environment in which phylogenetic development has taken place. In the first near-volcano environments, which applied to the subnuclear entities, water was relatively scarce, which explains the high concentration of the constituents in the nucleus. The mud of the earth’s crust is richer in water, which explains the difference between the nucleus and the cytoplasm, with the latter richer in water. The sea was the environment for the metazoic compartment, which explains the richness of water in this compartment. The so-called “internal sea’’ consequently can be seen only in the metazoic compartment. With the passage into the terrestrial environment with its air medium, the water again becomes scarce and has to be conserved. The circulation of water between compartments is governed by osmotic forces which are determined by the original rich¬ ness in water of the respective environments. The importance of water circulation appears evident when an abnormality in its distribution occurs. Water arriving in a compartment—alone or with a cation—in an amount above that corresponding to the constant for that compartment, is separated from the constituents of the entity in order to reestablish the characteristic constant value. Such separation of abnormal amounts is accomplished according to the compartment, through the appearance of vacuoles, edema, exudates or diuresis. A nimals and Plants The concept of hierarchic organization in which each entity can conserve its own environment allows us to consider in a new light various other problems of living organisms. One concerns the fundamental differences between animals and plants. Analysis of the constituents of the metazoic secondary part provides a new criterion for distinguishing between animals and plants and gives logical meaning to its distinction. Animals can be characterized as having sodium as the cation of their metazoic compart¬ ment; from the cell level on, they have had the sea as their temporary or even permanent environment. Plants, on the other hand, have potassium as the principal cation for their metazoic compartment, indicating that, from the cell level on, they have had the earth’s crust as their environment,

tized b> Google

uiluiMdi iruni

UNIVERSITY OF MICHIGAN

BIOLOGICAL

ENTITIES

/

31

passing thus directly from mud to air. By their actual attachment to the soil, plants continue this relationship to the mud. Their relative immobility is in accord with continuation of the terrestrial-air environment in their development. The mobility of animals, on the contrary, can be seen to have its origin in the fact that they have had the sea as their environment at least for a period of time, i.e.t from the cell period until the appearance of those animals which left the sea. We can interpret the appearance of cellulose and lignin as part of the plant-sustaining means which would bring to plants indispensable external protection against the hardness of the soil environment. Cellulose and lignin are not necessary for animals which experienced much of their evolution in the sea. Multiplication The hierarchic organization of organisms, with the conservation of successive entities, puts the problem of entity multiplication in a new light. According to the hierarchic organization concept, the multiplication of a complex entity means the reproduction of the entire series of hierarchic entities forming it In this process, the intervention of each hierarchic entity appears highly individualized. And this applies not only for the morphologically identifiable entities, but even for the most primitive enti¬ ties. The difference between the role played by the principal and secondary parts becomes capital for these processes. While for each entity the princi¬ pal part has to be built as such, the parts corresponding to the secondary parts are taken from the immediate environment. The quantitative dispro¬ portion between some principal and secondary parts makes the role of the first difficult to be recognized. The complex entity, through changes that are the reverse of those of ontogenetic and phylogenetic hierarchic develop¬ ment, separates the successive principal parts which characterize it. With the replication which takes place the division occurs successively for these hierarchic entities. In scissiparity the division morphologically occurs at the cell level; in karyokinesis, it can be identified at the chromomere level and certainly takes place much lower in the hierarchic entities. In replica¬ tion in general, different constituents available are adequately changed by the respective principal part to form the necessary secondary parts. Through these changes the same processes are reproduced which origi¬ nally occurred when the entity had been phylogenetically organized. With the individualization of the low hierarchic entities the problem of replication is simplified. Once replication occurs, the same process takes place successively for the progressively higher levels. Above chromomeres this appears very clear in karyokinesis.

Digitized

by Google

UNIVERSITY OF MICHIGAN

32

/

RESEARCH

IN

P HYSIO P ATH OLOO Y

After the chromomeres divide, two or four chromonemata appear. The process goes on within the chromosome, nucleus and cell. In order to protect its individuality each hierarchic entity is protected during its divi¬ sion. The chromosomial membrane, the cellular cytoplasm and the cellular membrane continue to protect the respective entities as they divide. The cell itself divides only when the two nuclei have had their protecting mem¬ branes rebuilt. In the division and multiplication of a complex entity, the return to entities as low as subnucleic parts indicates the relative importance for the characterization of the complex entity and for the conservation of its par¬ ticular properties of the parts added during the hierarchic development. The entity must, in fact, rid itself of these added parts which, although they have other importance, have a secondary role even in the processes of multiplication. It is interesting to note that a similar return to more primitive com¬ ponent entities also occurs, although it is less pronounced, when an entity, tissue, organ or organism has to fight a noxious intervention. The defense is passed progressively from the organ to the tissues and from these to the cells. In effect, there is a renunciation of added parts during these moments of crisis. Even at the cell level, a similar process is seen. The added parts, represented by the protoplasmatic formations, disappear. The almost nondifferentiated cell fights the noxious factor at the lowest levels of its organ¬ ization. Life and Death We have seen that the term “biological realm” can be applied to hier¬ archic development starting from the N-C-N-C radicals. We have employed this term for didactic convenience although it is unrelated to the commonly accepted concept of life. The study of hierarchic organization also led us to consider a concept of life and death which, while retaining some of the common meaning, also accords with the phenomena of hierarchic organ¬ ization. In the complex entity, each lower level entity lives and dies with relative independence. An organ can be dead and yet have living cells in it for a time. There are always dead cells to be found in living tissues and organs. It is the relative independence of the different hierarchic enti¬ ties making up a complex entity that explains these seeming peculiarities. Our concept of life and death stems from consideration of the nature of hierarchic entities. We have seen that all matter in nature, from the simplest to the most complex entity, is a result of heterotropy. The per-

Digitized by

Google

UNIVERSITY OF MICHIGAN

BIOLOGICAL

ENTITIES

/

33

sistence of constants proper to each entity is distinctly opposed to homotropy. Life in its broadest sense, corresponds to the capacity of an entity to maintain heterotropy by conserving its characteristic constants. The life of any entity appears to be synonymous with conservation of its constants. An entity dies when it has permanently—that is, irremediably—lost its capacity to conserve the constants which characterize it. Death then repre¬ sents exhaustion of heterotropy for the specific entity. The fact that, in essence, life appears to be synonymous with the con¬ servation of constants and is heterotropic, relates it, and especially its origin, to one of the important sources of heterotropic force, solar energy. A distinction has to be made between heterotropy as one of the funda¬ mental laws of nature and the means by which it is exerted. Solar energy, with all of its quantas, would greatly increase the effects of heterotropic forces in nature. It would not create such forces but would simplify them and extend their applications. The origin of matter and, as we have seen above, of entities, biological or nonbiological, is in the final analysis the result of heterotropic forces. External conditions qualitatively and quanti¬ tatively influence operation of heterotropic forces. The sun’s heterotropic contributions have to be considered under this aspect. Through the quantas it disposes of, solar energy has not created life, as conceived above, but by permitting more and more entities to appear, has greatly facilitated their extension. Its effect, although certainly not limited to any group of entities, seems to be especially important to those forming the biological realm. Similarly, the effect, of a special type of energy, radiation, also must be considered. Radiation appears to be related to the elements, and will be discussed in a later chapter devoted to the elements. Since life itself is related to changes directly aimed at conserving con¬ stants, in this broadest sense it is no longer limited to the specific group of entities found in the “biological” realm. Life has the same meaning for an atom, crystal or micelle, as for a cell, organ or organism. It is for this reason that knowledge of the mechanism through which constancy is achieved becomes of great importance in the study of all matter and espe¬ cially of the biological realm. Maintenance of Constants To study the mechanism used to maintain constants, we must define exactly what constancy means. According to Cannon’s principle of homeo¬ stasis, constants have been considered to correspond to a dynamic balance that results from the continuous operation of two opposing factors. And

Digitized

by Google

UNIVERSITY OF MICHIGAN

34

/

RESEARCH

IN

PHYSIOPATHOLOOY

it was conceived that by acting concomitantly as coupled antagonists, these factors or groups of factors insure constants. The intervention of these two opposite factors becomes apparent only if an exterior cause upsets their balance. However, our study of the processes through which dynamic balance is maintained has permitted us to recognize a different mechanism than the one which is commonly accepted. A value considered to be a constant for an entity is not fixed or static. It represents, rather, a statistical value, the result of a series of dynamic changes which must also be considered in terms of time. Consequently, a constant has to be seen not only as the average value of a series of organ¬ ized changes, but also must be identified by the characteristics of the varia¬ tions. An average value around which variations occur thus represents the first attribute of a constant. The second attribute is the existence of a rhythm in the variations, the third involves intensity of variations. For instance, when we say that human body temperature is constant, we mean that 37°C is average value for oral temperature, and also that body tem¬ perature presents characteristic variations having a 24-hour rhythm and also that the occurring changes consist of variations of a few tenths of a degree above and below the average value. The two antagonistic intervening factors do not operate concomitantly to maintain a constant value, but rather act alternately, each being pre¬ dominant for a period of time. The result is not a continuously steady value for the constant, but an oscillatory movement with successive passages from one side to the other of the average value. This oscillatory movement appears to be the general rule throughout nature, prevailing in everything from the waves in the smallest subatomic particles to the pulsation of the universe. The rhythm periods appear to correspond to environmental rhythms. A rhythm related to the day, for instance, is seen for temperature. In other constants we recognize a 12-hour rhythm which could correspond to that of the ocean tides. Other rhythms, with periods ranging from two hours to a few minutes are seen for several changes occurring in blood. There are also some in which the influence of the moon is evident; for ex¬ ample, the hypophysis-ovarian cycles; and for others, the influence of the seasons is apparent. Teleologically speaking, balance represents a very effective method for maintaining constants. Any deviation in any direction as a result of an external intervention will be counteracted by the opposing phase of the oscil¬ latory balance. This occurs because of the existence of two phases of the

Digitized by GOl >glC

UNIVERSITY OF MICHIGAN

BIOLOGICAL

ENTITIES

/

35

oscillatory movement itself. Such would not be the case if there were fixed values for constants. Related to the pattern of the organization of matter in general, this oscillatory movement can be considered to be another instance in which the two opposite fundamental forces of heterotropy and homotropy, which are basic to progressive hierarchic development itself, also operate. This oscil¬ latory balance can be related ultimately to the alternate successive interven¬ tion of the heterotropic and homotropic trends in the organization and the manifestations of entities existing in nature. Dualism The concept of dynamic oscillatory balance is of great importance in the study of biological phenomena. Coupled factors with opposite prop¬ erties characterize all constants and are involved both in the processes through which constants are maintained and in their manifestations as well. Recognition of this dualism in all biological phenomena has been of great value in the investigation of normal and abnormal physiology. According to our concept, dualism results from the alternate, not con¬ comitant, operation of two opposing factors. And, as we have seen, these factors ultimately can be related to the two fundamental forces in nature, homotropic and heterotropic. Thus, in a unified concept, in every phenome¬ non in which dualism appears, one force will be homotropic the other will be heterotropic. Homotropy is related to fulfillment of electrostatic forces, and has general coulombian electric character. Heterotropy is quantum-like and organizational. Homotropy would keep entities simple. Heterotropy would lead to more organized bonds and to more complex synthesis. In every phenomenon studied, these characteristics of the two fundamental forces have permitted dualism to be recognized and interpreted. The dualistic view has become our basic approach for all of the problems related to matter and, more specifically, to biological entities. The dualistic concept of intervening forces brings an entirely new light in any analysis in which a graphical representation is different from a straight line. From the curves of spectral analysis of constituents to those of complex phenomena, the existence of oscillations reveals the interven¬ tion of opposed forces and offers a valuable mean to study them. This broad approach has a special field of application in biology. Dualism can be further recognized easily in the manifestations of the biological entities, in their function and in the substances composing them. In the case of the elements, such a dualism can be related to atomic struc¬ ture and the properties of the electronic shells, as will be seen below. In

Digitized

by Google

UNIVERSITY OF MICHIGAN

36

/

RESEARCH

IN

PHYSIOPATHOLOOY

complex molecules, a simple form of dualism can be seen in acidity and alkalinity, electrophily and nucleophily or, furthermore, in positive and negative electrical characteristics. We will see later, how important dualism is for the different groups of constituents and how, without this dualistic concept, it would be difficult to understand the roles of most of these con¬ stituents in biology. In part, as a consequence of the separation of the constituents into two groups, dualism can be observed easily in the hierarchic organization of higher entities. Dualism appears in the relationship between primary and secondary parts, the first having a more positive character than the second. The study of cancer manifestations under this dualistic aspect has been highly rewarding and is the subject of the following chapters. In a more concrete step, the dualistic concept has provided new under¬ standing of abnormality. Normal and Abnormal

A normal entity can be conceived of as one which is able to maintain its constants with their characteristic values, rhythms and intensities by means of the alternate operation of homotropic and heterotropic forces. A normal entity, thus, can be defined as one having constants within the limits that statistically characterize this particular kind of entity. We can define the abnormal entity as one in which a constant's characteristics—average value, rhythm, intensity—are altered. It is alteration, without complete loss of the characteristics of constants, that differentiates abnormality from death. In death the constants themselves are irremediably lost. This defini¬ tion also distinguishes abnormal from physiological manifestations. In the physiological manifestation, oscillatory movement persists and only its in¬ tensity is influenced, usually becoming exaggerated. As expected from the dualistic concept, abnormal changes can take place in either of two opposite directions and this is a significant fact of abnormality. The two possibilities are inherent in the oscillatory balance characterizing the constant itself. It is the offbalance, resulting from the exaggerated predominance of one of the coupled factors over its antagonist, which leads to the abnormal. Persistent predominance of one factor ab¬ normally affects, and even suppresses, normal oscillatory rhythm. For each normal condition, then, two opposite abnormalities are pos¬ sible. By relating the abnormal condition to one or more altered concepts, and the alteration in each constant to one of the dual changes possible, a new systematized analysis of the abnormal becomes feasible. The large number of constants which compose each entity and which can become

Digitized by GOC >glC

UNIVERSITY OF MICHIGAN

BIOLOGICAL

ENTITIES

/

37

abnormal help not only to explain the great variety of abnormalities but also offer a means of obtaining analytical pictures of disease. It is with this approach that we have tried to study pathological condi¬ tions, with special emphasis on cancer. This study is presented in the fol¬ lowing pages.

Digitized by

Goo

Original from UNIVERSITY OF MICHIGAN

CHAPTER

CANCER AS AN ORGANIZED CONDITION

In the concept now most widely accepted, cancer is considered to be the result of abnormal changes within cells. Although it is admitted that the disease may have different etiologies, it is the cell which is regarded as the pathogenic entity. A group of specific changes in the cells is believed to represent the fundamental abnormality. In today’s prevailing outlook, differences between tumors are attributed to the multiple secondary characteristics present in the diseased cells along with a primary specific anomaly. The complex clinical manifestations of cancer are further explained in terms of the relationship between cancerous cells, as pathogenic entities, and the whole organism. Clinical evolution, from local innocuous process to lethal disease is related to anatomical spread of cancerous cells from their original site. Abnormal metabolic changes seen in the organism are believed to result from the influence exerted by functional abnormalities of the cancerous cells. In a still nar¬ rower view, cancer is considered to be the result of abnormality of a single specific function of the cell—its growth. Qualitatively and quantitatively, abnormal growth has been considered to be the capital factor in the patho¬ genesis of the disease. (292) In contrast to this classical view, our studies have led us to regard cancer as something other than an abnormality limited to the cell alone. As we have seen, the organism is a complex hierarchic organization of different biological entities. We sought to determine where cancer fits in this complex organization. Can cancer with its manifestations and its evolu¬ tion be better understood if systematized in accordance w ith the hierarchical organization of the organism? Can both manifestations and evolution be related not alone to a cellular abnormality but rather to a progressive par38

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

CANCER AS

AN

ORGANIZED CONDITION

/

39

ticipation in the disease of the different hierarchic levels of the organism? We have found that such participation cannot be analyzed readily in the advanced cancerous subject with so many and such varied manifestations of the disease already present. Similarly, incipient cases with a paucity of clinical manifestations are not ideal for the purpose. It was only by follow¬ ing the successive appearance of manifestations during the evolution of cancer that their relationship to the level of hierarchic organization involved could be clearly seen. Identification of the level involved at each point in the development of cancer was greatly facilitated by conceptually separating the clinical evolu¬ tion of the disease into a series of successive phases and identifying the changes which characterize the passage from one phase to the next. We have chosen to call these phases precancerous, noninvasive, inva¬ sive, painful, preterminal and terminal. We will briefly identify them and their salient features here. Precancerous Phase In the precancerous phase, the disease is not clinically apparent. Yet this phase has been recognized as pathogenic in experimental carcinogenesis and its characteristic changes also have been identified in human subjects. Morphological changes—abnormalities in size and form—can be observed in the chromosomes. These changes are not identified as related to cancer in human subjects except where multiple centers of cancerization are found (as in the stomach, for instance). (Note 1) These chromosomal abnormal¬ ities can be considered to be precancerous lesions, since experimental carcinogenesis has indicated that these changes precede the appearance of cancerous cells. In terms of hierarchic organization, then, the precancerous phase can be considered to be limited to the subnuclear levels. Noninvasive Phase In the noninvasive phase, also known as “cancer-in-situ,” abnormal intra-epithelial cells are present. The abnormality involves two changes. One, morphological, affects the nucleus; the other affects arrangement of the cells in the epithelium. The abnormal changes in the nucleus in this phase have been widely studied in exfoliative cytology. (Note 2) Abnormality in this phase appears to be limited entirely to the nucleus. The cells continue to have an almost normally differentiated cytoplasm, a fact which originally led to the description of this phase as “cancer of dif¬ ferentiated cells.” Besides the nuclear changes, cells in this phase show, histologically, an anarchic arrangement different from the regular disposi-

Digitized b

Google

UNIVERSITY OF MICHIGAN

40

/

RESEARCH

IN

PHYSIOP ATHOLOGY

tion which is one of the basic characteristic of the epithelium. Since the regular relationship between the cells forming epithelium can be attributed to dipolarity, the anarchic disposition seen in this phase of cancer can be ascribed to loss of cellular dipolarity. Cancer-in-situ, in terms of hierarchic organization, would appear to involve the level of the nuclei, and the noninvasiveness, characteristic of this phase, persists as long as the “cancerous” abnormality remains limited to this level, that is, as long as the cytoplasm of cells remains apparently unaffected. Invasive Phase This phase is characterized by irregular proliferation of cells and pene¬ tration into neighboring tissues. To the anarchic arrangements noted in the noninvasive phase, now has been added exaggerated growth. And the change of a noninvasive cancer into an invasive one can be considered to result solely from the addition of the new factor of abnormal growth. The invading cells will persist only if, concurrently, there is a loss of the defense mechanism of the invaded tissues, as will be seen later. Studies of invading cells have revealed, in this phase, an anomaly no longer limited to the nucleus but now encompassing the cytoplasm as well. Exfoliative cytology has shown an abnormal and rapidly disintegrating cytoplasm and this has served as an important diagnostic criterion. From the point of view of organization, it can be said that, with the participation of the cytoplasm, the disease has progressed from the nuclear to the cellu¬ lar level. Painful Phase Fain is the principal clinical manifestation characterizing the next phase of the disease. As we shall explain in greater detail later, pain arises from changes in the pH of the intercellular fluid that bathes sensorial nerve end¬ ings. For the moment, we can remark that biochemical changes now occur outside the cells, and, with the participation of interstitial formations, the disease has progressed to the tissular level. Preterminal and Terminal Phases In the next stage, the preterminal, biochemical changes affect the func¬ tion of various organs which may or may not in themselves contain cancer¬ ous cells. While some changes in function may be seen even before this preterminal phase, now, there is manifest impairment. And, while the in¬ vasion of an organ by cancerous masses is a factor precipitating the func-

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

CANCER

AS

AN

ORGANIZED

CONDITION

/

41

tional changes, invasion is not indispensable. Abnormal biochemical changes leading to serious functional impairments are seen in organs entirely exempt from tumor masses. With further progress of cancer, metabolic functions that are systemically important become abnormal. Later, we will analyze in detail these changes which affect the whole organism profoundly. For the moment we want only to note that, with these changes cancer passes from the clinically preterminal to the terminal phase. In the light of this systematization, cancer then appears to progress clinically in organized fashion as it passes from the relatively innocuous nuclear noninvasive cancer-in-situ to a lethal systemic disease, the progress being marked by the successive participation of different hierarchic levels of the organization. Table I sums this up. Table I Organizational Level

Subnuclear Nuclear Cellular Tissular Organic Systemic

Physio pathological Changes

Clinical Phase

Gene and chromosome anomalies Nuclear anomalies and atypical cellular arrangements Atypical growth Local pH changes Organic metabolic changes Systemic metabolic changes

Precancerous Noninvasive cancer Invasive cancer Painful cancer Preterminal cancer Terminal cancer

By extrapolation, a similar progressive participation of hierarchic en¬ tities can be conceived of below morphologically recognizable levels. This would permit us, as a working hypothesis, to attribute the pathogenesis of cancer to abnormalities in nucleo-proteins or, even lower in the scale, to abnormalities in histones or alkaline amino acids. (Note 3) This concept—of progressive participation of successive hierarchic levels in cancer—contrasts sharply with the view generally held today which places the entire burden of anomaly on the cancerous cell itself. The classical concept has led to the currently prevailing all-or-nothing approach in which therapeutic attempts are directed to the cancerous cells as the only avenue for controlling the disease at any moment of its evolution. Under our hierarchic concept, therapeutic possibilities can be extended beyond the cancerous cell. These considerations raise the question of the relative importance of the multiple changes which occur in cancer. Subnuclear and nuclear changes are of relatively little importance as long as there is no progress of disease beyond these levels. Corroboration for this can be found in the great num-

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

42

/

RESEARCH

IN

PHYSIOPATHOLOOY

ber of cases in which cancer-in-situ cells are noted in an organ, yet clinical cancer does not follow. In our concept, the changes which occur at levels above the nuclear are critical in the evolution of the disease and, as such, are the important pathogenic factors. On the other hand, as we shall see later, changes at higher levels similar to those encountered in cancer may occur independently of cancer, and without a sequence of changes at lower levels. It is only when changes at higher levels appear in proper sequence, affecting already abnormal entities of the lower levels, that clinical cancer results and the malignancy moves relentlessly from the noninvasive cancerin-situ to the terminal phase. This concept, then, focuses attention on all changes occurring at differ¬ ent hierarchic levels of the organization rather than on those in the cell alone. It emphasizes the importance of the relative independence which exists between the different hierarchic levels, an independence which gov¬ erns their participation in the complex condition which is cancer. From the therapeutic standpoint, then, it seems logical to suppose that, if the progressive participation of successive levels can be interrupted, many if not all of the noxious manifestations and the course of cancer can be favorably influenced. In view of this, it has been essential, first, to obtain more information about the cancer manifestations which are added as the disease takes its hierarchically progressive course and about the mecha¬ nisms that account for these manifestations.

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

CHAPTER

DUALISM

JTajs we have observed above,

dualism prevails in nature. The concept

of an oscillatory dynamic balance—the result of alternate operation of op¬ posed forces—has been of special value in the study of most of the physio¬ logical phenomena. Over the years we have also constantly observed that in most physiopathological manifestations, dualistic patterns can be recognized. This dualistic pathogenic concept has helped to guide our study of disease. In cancer, it has permitted better understanding of many processes and manifestations. It has also served as a basis for our attempts to influence cancer and other conditions therapeutically. It was in the study of pain that, initially, we found clear evidence of pathogenic dualism.

PAIN Many years ago, during experiments with an alcoholic extract of hu¬ man placenta as a therapeutic agent in terminal cancer cases, a curious ef¬ fect was observed. In some patients with painful lesions, administration of the preparation resulted in a decrease in the intensity of pain and even in its disappearance within a few minutes, with relief usually lasting for hours. In other cases, however, there was an opposite effect; pain increased in inten¬ sity within a few minutes after an injection. In some subjects, the exacerba¬ tion was so great and pain became so unbearable that the experimental treatment had to be discontinued quickly. In several cases in which the preparation was used in progressively larger doses, another noteworthy ef¬ fect was observed: after the first injections, pain decreased and even dis¬ appeared for several days, only to have a new pain arise as treatment continued. This new pain became more intense after each injection so that the therapy had to be discontinued. Patients clearly recognized the differ¬ ence between pains. The new one frequently had a burning character. 43

Digitized by

Google

original rrom

UNIVERSITY OF MICHIGAN

44

/

RESEARCH

IN

PHYSIOPATHOLOGY

Thus, it became apparent that one substance could increase pain in some subjects and alleviate it in others, and could even alter the nature of the pain in the same subject. Pain, as demonstrated by antagonistic re¬ sponses to a single agent, thus appeared to have a dual nature. Our im¬ mediate problem was to investigate this and its significance. Physiological and Pathological Pain

In discussing the sensation of pain, most authors have found it necessary to distinguish between different types of pain. Some have classified pain as: 1) spontaneous, or 2) provoked, according to its mode of induction. Others have defined pain according to its site of origin and quality as: 1) super¬ ficial or cutaneous, and 2) deep visceral or somatic. Superficial pain from skin and mucous membranes near body orifices has been described as bright or burning in quality, while deep visceral or somatic pain arising from mesenchymal structures, certain mucous membranes and viscera has been described as diffuse and aching in quality. In many respects, attempts to define and classify pain in these terms have served to confuse rather than to clarify the problem. That different types of pains do exist is an observation based upon com¬ mon experience. For example, when a stimulus of sufficient intensity is ap¬ plied to the skin for an adequate period of time, a sensation of pain is induced. This pain disappears rapidly when the stimulus is removed. But if the stimulus has been of such intensity and duration as to produce tis¬ sue damage, an after-pain may recur spontaneously some time after the stimulus has ceased. The original pain serves as a warning that the tissues are endangered. The after-pain, however, cannot be considered as a direct effect of the application of an external stimulus, but is rather a manifesta¬ tion of true tissue damage. As a first step, two categories of pain—one induced in normal tissue by external intervention, the other appearing as a pathological manifesta¬ tion of an existing lesion—were established. We called the first, which is a normal sensorial sensation, “physiological” or “sensorial” pain. The sec¬ ond, a symptom of an abnormal local condition, was called “pathological” or “symptomatic” pain. This separation helped to eliminate discrepancies otherwise encountered in the study of pain, discrepancies which result when two entirely different manifestations, one sensorial and the other sympto¬ matic, are studied under the same heading and investigated by the same methods. Pain may be induced in damaged tissues by various stimuli not of sufficient intensity to arouse pain sensations in normal tissues. This sensi-

Digitized by

Google

UNIVERSITY OF MICHIGAN

DUALI9M

/

45

tivity constitutes an abnormal response of tissues that have undergone pathological changes. Inflammatory, traumatic, circulatory, neoplastic or other pathological changes similarly may bring about either spontaneous pain or an abnormal degree of sensitivity of the involved tissues to external stimuli. There are, therefore, two general types of pain which are biologically different. The first is a direct response of normal tissues to external stimuli which serves as a warning of danger. The organism reacts to this type of pain by seeking to run or to fight. The second type of pain arises as a con¬ sequence of tissue damage or disease to which the body responds by at¬ tempting to put the injured area at rest. This second type of pain, whether spontaneous or provoked, superficial or deep, is biologically different from the first pain experienced following the application of sufficiently intense external stimuli to normal tissues. For purposes of further study, it would appear to be advantageous to distinguish between physiological or sensorial pain which is the response of normal tissues to noxious external stimuli, and pathological or symptomatic pain which is a manifestation of abnormal tissues. In the study of pain in all its aspects, it is necessary to keep this distinction in mind. While various investigative methods have furnished data concerning physiological pain, the information thus obtained is of very limited value when applied to the problem of pathological pain. However, it is pathological pain which con¬ stitutes the vital clinical problem, physiological pain being of concern in medicine primarily in the field of anaesthesia. (Note 1) Dualism in Pathological Pain It was only in pathological pain that a dual character was encountered. For one thing, it was noted that in some patients with chronic pain—associated with tumors, arthritis or other conditions—the pain intensity was not con¬ stant. In many of these patients, variations in pain intensity could be seen to follow a pattern. Although the variations usually are referred to as “spontaneous,” we could show that they were related to the time of day. Furthermore, the variations were not the same for all patients. In one group, pain was severe in the morning and diminished toward evening, while in another group, little or no pain was felt in the morning and exacer¬ bations occurred in the evening. The intake of food also had a dual influence. In some patients with tumors far removed from the gastro-intestinal tract, pain was increased by eating while in others pain decreased. Patients themselves often recognized this relationship and many whose pain was increased with the intake of

Digitized b

Google

UNIVERSITY OF MICHIGAN

46

/

RESEARCH

IN

P HYSIOP ATHOLOO Y

food refused to eat for fear of aggravating their suffering, while those of the other group wanted to eat whenever pain was severe in order to reduce its intensity. These observations on the influence of time of day and intake of food on pain led to the study of the acid-base balance of the body since this balance is known to be influenced by the same two factors—time of day and food intake. In a preliminary study we considered a special aspect of the acid-base balance of the body, that is, the several mechanisms involved and their possible intervention in the change of pain intensity. A study was made of blood pH, titrimetric alkalinity, C02 combining power, relative chloride distribution between erythrocytes and plasma, as well as urinary pH for the indications they furnish concerning the acid-base balance. The blood is highly buffered in order to avoid damage, through abnormal pH values, to cells in general and especially to those of the nervous system. Conse¬ quently, the variations in the blood pH are as limited as possible. Alkaline reserve and the chlorides repartition represent only part systems in the gen¬ eral acid-base balance. Titrimetric alkalinity, corresponding to the sum of ionized and nonionized constituents, furnish information of the broadest scale of the acid-base balance. Consequently it appears to be a highly significant measurement. Through the non-ionized constituents, it can vary greatly without influencing blood pH. It reflects thus otherwise hidden changes in the acid-base balance. We could show that alone, among all the variable factors of the blood acid-base balance, total titrimetric alkalinity of blood varies in parallel with the urinary pH. (Note 2) As an immediate result of this research, it was possible to utilize the changes in the urinary pH as an indication of the most important variations occurring in the systemic acid-base balance. This makes it possible to use changes in the urinary pH as an indicator of the relationship between acid-base balance and variations in pain intensity. Pain and Acid-Base Balance Changes

When changes in pathological pain intensity were studied in relation to changes of the urinary pH, a correlation could be established in the major¬ ity of cases. Two opposite kinds of relationship were observed when curves of the variations in pain intensity were compared with those of the urinary pH. Patients who had experienced pain associated with chronic pathological lesions over prolonged periods of time were instructed to record carefully the relative intensity of their pain at regular intervals, such as every hour.

Digitized b

Google

UNIVERSITY OF MICHIGAN

DUALISM

/

47

No analgesics were administered for at least six hours before or during the test period which was continued as long as possible, even for twenty-four hours. Patients were instructed to concentrate on a single painful area and to estimate the degree of pain intensity. They were told to consider an average degree of pain during each hour rather than momentary peaks during the observation period or the pain at the moment of recording. The

Hour

Fio. 6. A pain pattern is recognized by comparing the concomitant changes present in the curves of pain intensity with those of the urinary pH. The parallel variations of the two curves indicate an alkaline pattern with the pain more intensive when the urine is more alkaline, as seen in a case of carcinoma of the colon with painful ab¬ dominal mass.

degree was recorded in relative terms of no pain, slight, moderate, severe, very severe and unbearable, or as figures from 0 to 10. Urine specimens were obtained each hour immediately after the pain intensity observations were recorded and the pH was determined electrometrically. Two curves—for the hourly variations in pain intensity and for urine pH—were then plotted. Two distinct types of correlations were found. In the first, the two curves paralleled each other, the pain being more intense when the urine pH was higher, and less severe when the pH was lower. (Figs. 6 and 7) Because the maximal pain of this type of correlation is associated with a change toward alkalinity, this was called an alkaline pattern of pain.

Digitized b

Google

Original UNIVERSITY OF MICHIGAN

48

/

RESEARCH

IN

PHYSIOPATHOLOGY

FiO. 7. The alkaline pattern of pain in which the concomitant variations in the curves of pain intensity and urinary pH are parallel, seen in a case of arthritis.

In the second type of correlation, the two curves varied inversely, pain being most marked when the urine was most acid, and least so when the urine was most alkaline. (Figs. 8 and 9) This second type was called acid pattern of pain because of its association with a change toward acidity. Considering the highly subjective nature of pain, the inconsistencies which occur are minor. Fig. 10 shows these curves followed during days. The correlation between the pain intensity and urine pH curves are relative rather than absolute. The general level of urine pH apparently

Fio. 8 .An acid pain pattern is seen in a case of carcinoma of the prostate with meta¬ static bone lesions, in which the concomitant variations of the curves of pain inten¬ sity and urinary pH are divergent.

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

DUALISM

/

49

depends upon other factors. Consequently, only the fluctuations of the hydrogen ion concentration, rather than the absolute levels, are considered in this relationship to pain. Changes in pain intensity were found to have a similar dualistic corre¬ lation with other factors as well as the acid-base balance—with potassium content of blood serum, for example. Studies were made to compare the concomitant changes in pain intensity and in potassium content of blood serum. In several cases the acid and alkaline patterns of these pains were determined through the relationship to urinary pH variations. At different

Fic. 9. An acid pattern of pain recognized by the divergent variations of the curves of pain intensity and urinary pH is seen in a case of phantom limb.

moments, especially when the pain was markedly different in intensity, blood was obtained by finger puncture, and collected in glass capillaries. After clotting, the serum was immediately separated and the potassium content measured using a flame photometer. Curves of the values of pain intensity at these moments, established by the method previously men¬ tioned, and of the concomitant K+ content were compared. Figs. 11 and 12 show the two curves in two cases in which, the two pain patterns—acid and alkaline, were primarily recognized. The cases with high serum potas¬ sium values and with parallel changes between the two curves—pain in¬ tensity and K+ content—were seen to correspond to alkaline pain pattern; the other cases with less serum potassium and opposite variations of the two curves were seen to correspond to the acid pain pattern. We extended the study of the pain pattern, as revealed by concomitant

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

50

/

RESEARCH

IN

PH Y SI OPA TH OLOOY

variations of pain intensity and body acid-base balance, from cancer cases, in which a frank dualism had been seen, to other painful conditions. It was interesting to note that, in many conditions, pain can have one or the other pattern but there are some conditions in which only one pattern is consistently found. Pain following trauma of any kind—the pain of post-

Corcinomo of Reclum 1943

Courtesy of Dr. Mario Rognoni Fio. 10. The pain pattern can be recognized also through the characteristic opposite variations of the curves of pain intensity and urinary pH, followed during successive days—instead of hours—as seen in the above curves of a case of cancer of the rec¬ tum. (Courtesy of Dr. Rognoni)

operative and accidental wounds, burns and fractures, for example—al¬ ways has an alkaline pattern. This is also true for the pain of gallbladder colic. In other conditions, either pattern may be present and must be de¬ termined by analysis. For instance, the pain of neuritis and simple head¬ ache has an acid pattern in some cases, alkaline in others. In rheumatoid arthritis, an alkaline pain is almost constantly found. In osteoarthritis, the pain is of an acid type. In arthritic patients in whom

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

DUALISM

/

51

this relationship did not seem to hold, it was possible to recognize not only the existence of both rheumatoid and osteoarthritis but also to note that the pain pattern, as shown by test, was related to the more painful condition. We utilized the diagnosis of the type of pain present as an indication of the nature of painful processes. We will see later how this correlation has been confirmed by therapeutic trials.

Pain intensity

K+ in serum in mEq

Hours Fig. 11. Pain pattern and potassium in blood serum. The comparison of the con¬ comitant changes in the curves of pain intensity and those of the amount of potassium in blood serum shows parallel variations in a case with an alkaline pattern.

Two types of pain associated with two different conditions present in the same individual have been found to occur more frequently than ex¬ pected, although usually not simultaneously active. In most patients with two or more anatomically separated painful foci, parallel variations occurred between the curves of the different pains. Only in occasional cases were the two pains found to vary simultaneously but in opposite fashion. Their opposite patterns were well described by patients who observed “the two pains act as if they were part of a balance; when one goes up, the other goes down, and the opposite.” In Figure 13, the pain curve of lesion A is seen to vary inversely with the curve of urinary pH, while the pain curve of lesion B is parallel with the urinary pH curve. Thus,

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

52

/

RESEARCH

IN

P H Y S I OP A T H O L OGY

10 6

Pain Intensity

«• a 2 0

Fio. 12. Divergent variations between pain intensity changes and those of the blood serum potassium in a case of acid pain pattern.

Fio. 13. Pains. Acid and alkaline pains can co-exist on different lesions, as seen in a patient with multiple osseous metastases from breast carcinoma. Lesion A, which corresponds to an acid pattern, shows divergent variations between the curve of urinary pH and that of its pain intensity, while for lesion B, with an alkaline pattern, the variations of the curves of pain intensity and of urinary pH are parallel.

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

DUALISM

/

53

the pain of lesion A is of an acid pattern while that of lesion B is of alka¬ line pattern. Also interesting to note is the persistence of the same pattern for pains associated with chronic conditions. We have headache patients, for exam¬ ple, in whom, during the 20 years since we first determined the pattern of pain, there has been no changes of pattern. In others, on the contrary,

Fig. 14. The changes induced in the pain intensity by the administration of an acidi¬ fying agent indicate the pattern present. Pain with an acid pattern is intensified fol¬ lowing oral administration of 1.5 cc. of a 50% sol. of phosphoric acid. Urinary pH changes reflect the induced systemic acidification.

changes occur rapidly. In a case of sciatica, we have seen rapid and fre¬ quent changes in pattern, especially in response to therapeutic measures. Worthy of being noted is the correlation found between variations in pain intensity and changes in the acid-base balance of the body even in cases in which nerves are directly involved in lesions and in which a mechanical pathogenesis usually has been accepted. This would indicate that the chemical factor mentioned above has a role in the pathogenesis of pain even in these cases.

Acidifying and Alkalizing Agents We next demonstrated the cause-effect correlation between acid-base changes and variations in the intensity of pain. Administration of acidi¬ fying or alkalizing substances could induce the same changes in pain intensity as those caused by spontaneous variations in the acid-base bal¬ ance of the body. The relationship between acid-base balance changes and pain intensity was thus investigated by administering strong acidifying and alkalizing

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

54

/

RESEARCH

IN

P H Y S I O P A T H OL O O Y

agents to patients after the type of pain-urinary pH correlation had been determined. Administered orally, strong acidifying substances, such as phosphoric acid, ammonium chloride or mono ammonium phosphate, increased the severity of pain with an acid pattern, (Fig. 14) and reduced the severity of one with an alkaline pattern. (Fig. 15) At the same time, it caused a lowering of the urine pH.

Fig. 15. Pain with an alkaline pattern is relieved by oral administration of two doses of 1.5 cc phosphoric acid (50% sol.). Urinary pH changes reflect the systemic acidi¬ fication.

Sodium bicarbonate or ammonium acetate in quantities that alkalinized the urine increased intensity of pain with an alkaline (Fig. 16) and diminished intensity of pain with an acid pattern. (Fig. 17) These changes of the systemic acid-base balance induced by admin¬ istration of strong acidifying or alkalizing agents explains how similar changes, when they occur spontaneously, affect pain intensity. The effect

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

DUALISM

/

55

Fig. 16. Pain with an alkaline pattern is intensified by oral administration of 5 grams of sodium bicarbonate. Urinary pH changes reflect the systemic alkalinization.

may be to increase or decrease the intensity, depending upon the pattern of the existing pain. It is interesting to mention that similar changes of the systemic acid-base balance, spontaneous or induced by the administration of acidifying or alkalizing agents, do not influence either the threshold or intensity of physiological pain. We have often utilized this response to alkalizing or acidifying substances as a method of recognizing the acid or alkaline pattern of pain. (Fig. 18 bis) Dualism in Local pH Measurements Since it had been observed that a definite correlation exists between the variations in pain intensity of abnormal foci and changes in the gen-

Fio. 17. Pain with an add pattern is relieved by oral administration of 5 grams of sodium bicarbonate. Urinary pH changes reflect the systemic alkalinization.

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

56

/

RESEARCH

IN

PHYSIOPATHOLOGY

eral reaction of the body, it was desirable to ascertain what changes were taking place within the abnormal foci themselves at the same time. Patients with easily accessible superficial lesions, especially tumors, in which painful areas could be well localized, were employed in these experi¬ ments. The pattern of pain, acid or alkaline, was first determined in the manner previously described. Local pH determinations were then per-

Co of UUrut Hours 35

45

55

05

Co 15

25

35

45

of Prostate 55

05

f5

25

Fio. 18bis. The response of the pain of a lesion to an agent permits to identify the acid or alkaline pattern present. The effect of an acidifying and alkalizing agent cor¬ responds to an increase or a decrease in pain intensity, according to the pain pattern present. First row, left side—acid pattern, right side—alkaline; second row, left side— acid, right side—alkaline; third row, right side—alkaline, left side—acid pattern.

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

DUALISM

/

57

formed. Special glass electrodes* were used for this purpose and determina¬ tions were carried out employing a sensitive pH meter. The tip of the electrode was placed on the surface of the area to be tested if ulcerated, or was introduced into the tissue to be tested through a small incision. In reality this gives a measurement of the pH of the local interstitial fluid. Urine pH and local pH determinations were then performed at different times corresponding with spontaneous variations in the pain intensity ex¬ perienced by the patient. Simultaneously, the pH values of normal tissue areas and, when possible, of nonpainful tumor areas were determined. Similar studies were carried out after administration of strong acidifying and alkalizing agents. Many difficulties were encountered both in the choice of suitable clini¬ cal subjects and in techniques. Neoplasms proved to be the simplest type of painful abnormal process to employ. The neoplasm had to be located in a readily accessible region so that the electrodes could be introduced into an ulcerated area or through small incisions. The patient had to be able to very accurately localize the area of pain since considerable differences in pH values were found to exist in different parts of the same lesion. The pain had to be superficially localized because accurate determinations in the depths were not possible. Finally, the complete cooperation of the patient was essential. The data obtained for a patient with an ulcerated, profusely draining carcinoma of the breast is recorded in Table II. Pain was most intense Table II Observations in a Case with Alkaline Pain Pattern

Treatment (oral)

Phosphoric acid 50%, 2 cc. Sodium bicarbonate 5 grams

pH Normal Tissues

Pain Intensity

pH Urine

pH Tumor

None Moderate Very severe

5.4 6.2 7.1

Slight

5.5

7.3

7.9

Unbearable

7.8

7.4

8.8

7.6 8.1 8.5

when the acid-base balance of the blood, as reflected in the urine pH changes, was relatively most alkaline, and was less intense when the bal¬ ance was more acid. The pH values of the painful areas of the tumor in • Supplied by Hartman and Braun, Paris.

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

58

/

RESEARCH

IN

PH Y S I OPA TH O LOGY

this case showed considerable lability under the influence of spontaneous changes in the general acid-base balance of the body, reaching a high of 8.5. At this time, the pain was very severe. The pain became unbearable following oral administration of 5 grams of sodium bicarbonate, and the pH within the same tumor area reached 8.8. The pH of the normal tissues in this case, even after the administration of strong alkalizing agents, never exceeded 7.4, while the tumor pH was never below 7.6. The findings in a case with acid pain are recorded in Table III. This Table III Observations in a Case with Acid Pain Pattern

pH TUMOR

Treatment (oral)

Pain Intensity

pH Urine

pH Normal Tissues

Painful area

Nonpain¬ ful area

None Moderate Severe

7.0 5.8 5.3

7.4 7.3

6.8 6.3 5.8

7.2 7.1 6.9

5.0

7.3

5.5

6.8

6.6

HOI

Phosphoric acid 50%. 1.5 cc. Unbearable Sodium bicarbonate 5 grams None

7.4

patient had an extensive sarcoma of the face which was not ulcerated but involved the skin. Pain was most intense when the blood titrimetric alka¬ linity was relatively low and less severe when the alkalinity was higher. The pH values in the tissues of a painful area of the tumor were always more acid than the values found in another nonpainful area. The pH of the nonpainful area was slightly below that within normal tissues. Spon¬ taneous changes in the acid-base balance of the body brought about a reduction of the pH of the painful tumor area to 5.8, at which time the patient reported severe pain. The nonpainful tumor area had a pH of 6.9 at the same time. Following administration of 1.5 cc. of 50% phosphoric acid, pain became unbearable and the pH within the tumor tissues of the painful area fell at once to 5.5. At the same time, the nonpainful tumor area pH was 6.8 and the normal tissue pH was 7.3. Similar results were obtained in other cases and led to the following conclusions: The pH values of the interstitial fluid of painful lesions studied in vivo differ from those of normal tissues, the hydrogen ion concentration being either higher or lower than that of normal tissues of the same in¬ dividual. The pH of painful abnormal tissues is much more labile and

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

DUALISM

/

59

extremely sensitive to general body pH changes. Spontaneous or induced variations in the acid-base balance of the body produce slight changes or none at all in the pH of the interstitial fluid in normal tissues, but give rise to more pronounced changes of the pH within painful pathological tissues. Through this research, we have thus been able to connect pathological pain to the pH of interstitial fluid of painful lesions. A further connection could be made with the richness of the interstitial fluids in potassium. In the alkaline pattern of pain, more potassium was found in the interstitial fluids. The presence in these fluids of potassium—the cation of the cytoplasma—in higher amounts than in normal conditions was seen to induce pain. The subcutaneous administration of potassium compounds was seen to be painful, while similar salts of sodium were well tolerated. As a local acidosis was found in lesions having an acid pain pattern, a local alkalosis and an increase in potassium content appeared in those with an alkaline pain pattern. The intensity of pain in this case was found to be propor¬ tionate to the degree of abnormal deviation of the local pH and to the abnormal amounts of potassium in the interstitial fluids. In addition to variations in the acid-base balance of the body, variations in the amount of serum potassium appear able to alter pain intensity in cases with an alkaline pattern. This correlation is further explained below by the place of potassium in the organization. Oxido-reduction Potential Differences indicating the same dualism were also found in other mani¬ festations in painful lesions. The oxido-reduction potential was measured in tumors with pain. Patients chosen were those with easily accessible super¬ ficial tumors in which painful areas could be localized. Platinum needle electrodes were introduced in the painful areas through small incisions or, if the lesions were ulcerated in the lesions themselves. The measurements of the potential present were made using a Beckman pH meter. As had been the case for the pH, it appeared important that the patient be able to indicate clearly the painful areas. Because exact location of these areas in the depths was almost impossible, superficial lesions usually were chosen for these determinations. In general, in lesions with an alkaline pattern, the meas¬ urements showed high values (such as from +100 to +350 millivolts) while in lesions with pain of the acid pattern, the values were low (such as -2 to —15 millivolts).

Digitized by

Google

UNIVERSITY OF MICHIGAN

60

/

RESEARCH

IN

PHYSIOPATHOLOGY

Abnormal Substances Changes in the local pH, like changes in acid and alkaline patterns, could be related to the appearance and subsequent accumulation of differ¬ ent substances in the lesion. Increased concentration of lactic acid was found in the interstitial fluids of acid pattern lesions, while increased con¬ centrations of sodium and especially potassium ions were found in the interstitial fluid of lesions with an alkaline pattern. Processes leading to a local acidosis are known and ascribed to the well-known anoxybiotic metabolism of carbohydrates. They result from lack of the “respiratory” oxybiotic phase of carbohydrate metabolism, with the consequent conversion of pyruvic acid into lactic acid. Only part of the lactic acid is changed into glycogen through the Pasteur-Myerhoff reaction, and an accumulation of lactic acid results. While the presence of lactic acid is well known, its presence has not previously been related to pain or other manifestations. We could show this correlation in some cases. (Note 3) The scientific literature offered no information concerning the appear¬ ance of alkaline compounds. We were able to establish that the presence of sodium ions coincides with another anomaly found in these lesions—a high fixation of chlorides in the lesions themselves. Values of 1600 mgr. of Cl., or even higher, per 100 gms. of wet tissue were found in these lesions instead of about 400 mgr./100 gms. measured in normal tissues. The local alkalosis and the resulting alkaline pain pattern could thus be correlated with an abnormal sodium chloride metabolism at the tissular level in which with chloride ions fixed by the cells, sodium ions remain free to combine with carbonate anions and form alkaline compounds. If the abnormal NaCl metabolism occurs in the interstitial fluid, the subsequent alkalosis induces pain. We will see later how abnormal NaCl metabolism also takes place at other levels of the organization. In these cases of alkaline pattern of pain, the fact that abnormal amounts of sodium ions still enter the cells will result in a loss by these cells of potassium which will accumulate in the pericellular fluids, and form alkaline compounds. An immediate conclusion that could be drawn from these studies was that there is a definite dualism in pathogenesis of pain originating in abnor¬ mal tissues and that the two pain patterns evidenced in lesions with acidosis or alkalosis of the interstitial fluids indicate that processes of two opposite natures go on at the tissular level.

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

DUALISM

/

61

OTHER ACID AND ALKALINE SYMPTOMS Using the same method of investigation as in the study of pain, a rela¬ tionship between variations in intensity of certain other symptoms and variations in urinary pH could be found. Acid and alkaline patterns of itching could be recognized. The same patterns could be found for vertigo and impaired hearing. Among psychiatric manifestations, manic-depressive states showed changes that could be related to acid-base variations. The correlation between dyspnea and acid-base variations was contrary to what we expected. Classically, dyspnea is believed to be associated only with an increase of acidity of blood. However, both acid and alkaline pat¬ terns of dyspnea were observed, and could be related more directly to changes at the tissue level. We will review here the pathogenesis of itching, vertigo, dyspnea, and other conditions, under this dualistic aspect.

Itching The problem of itching is interesting from other than the therapeutic point of view, since little is known regarding the nature and cause of this condi¬ tion. Various hypotheses have been offered but have failed to explain its pathogenesis. Our interest in itching originated during the study of pain and led to an hypothesis which allows us to approach the problem from a new angle. By analogy with pain, we separated itching into two types: physiological, as the response of normal tissues to external stimuli; and pathological, as a sensation arising within diseased or damaged tissues. Tickling the normal skin or even stimulating it through heat, cold, etc., may cause a sensation of itching and lead to scratching. Certain mucous mem¬ branes, such as those of the nose, and the skin around natural orifices, are especially sensitive to such stimulation. This type of itching, as a response of normal tissues is physiological or sensorial. Under pathological conditions however, the skin, mucous membranes and other formations may itch without external stimulation or in response to stimuli which ordinarily do not produce this sensation. The itching then can be considered as a manifestation of diseased or damaged tissues and, as such can be described as pathological. Just as does pathological pain, pathological itching represents a symptom related to abnormal changes already present. (Note 4) In spite of their relative independence, the fact that similar funda¬ mental mechanisms are involved in the production of itching and pain explains certain characteristics they have in common. Like pathological

Digitized by

Google

UNIVERSITY OP MICHIGAN

62

/

RESEARCH

IN

PHYSIOPATHOLOOY

pain, pathological itching varies in intensity with the time of day. Patients with chronic pruritus are aware of this. Some have more itching in the morn¬ ing, others experience exacerbations at night. The same dualism is seen with intake of food. For these reasons, the relationship between changes in acid-base balance of the body, as reflected in the urinary pH, and varia¬ tions in intensity of itching was investigated. Patients with long standing pruritus associated with a variety of chronic skin conditions were studied. They were asked to note over periods of six to twelve hours the changes in itching intensity. Evaluation of the changes was made by the patients themselves, using a series of qualifications such as none, slight, moderate, severe, very severe and unbearable, or a scale ranging from 0 to 10. They were instructed to consider the average inten-

Hours Fig. 20. The alkaline pattern of itching is recognized in a case of senile vulvar pruritus, through parallel variations of the curves of the intensity of the itching and of the urinary pH.

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

DUALISM

/

63

sity of their itching for each hour, rather than to indicate the maximum intensity at the exact time of recording. Voided urine specimens were obtained at the end of each hour. The pH of the urine specimens was de¬ termined electrometrically. A graph was plotted to compare the variations in the subjective data furnished by the patient with the concomitant hourly changes in the pH of the urine. It was usually necessary to repeat the test several times before the patient appeared able to satisfactorily evaluate the changes in the intensity of the symptom for hour-long periods rather than

Hour Fig. 21. An acid pattern of itching is recognized in a case of pruritus ani through the divergence in the concomitant variations of the curves of itching intensity and uri¬ nary pH.

for just the moment of recording. (We also tried to judge the intensity of itching through the frequency, intensity and duration of scratching, as noted by an observer, but without success.) Fifteen patients were studied and, because of the limited number, the results are presented as merely preliminary.

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

64

/

RESEARCH

IN

PHYSIOPATHOLOGY

In four cases, the curves of itching and urinary pH did not show any definite correlation even after repeated tests. Of the remaining 11 cases, 7 showed a distinct parallelism of the two curves, and in the other 4, an inverse relationship between curves was apparent. The graphs obtained in two characteristic cases are presented here. (Figs. 20 and 21)

Hours Fio. 22. Administration of phosphoric acid—1.5 cc phosphoric acid, sol. 50%—in¬ duces together with an acidification of the urine, an increase in the intensity of the itching with an acid pattern.

There is a distinct parallelism between the two curves in Figure 20, indicating that itching was more intense when the urine was relatively more alkaline, and slight or absent when the urine was more acid. We have con¬ sidered this as an “alkaline pattern” of itching in accordance with the designation for pain. An inverse relationship between the two curves is seen in Figure 21. In this case, itching was more intense when the urine

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

DUALISM

/

65

was more acid, and less severe when the urine was more alkaline. This represents an acid pattern. The effect of a strong acidifying agent, phosphoric acid, in cases with acid and alkaline itching, is illustrated in Figures 22 and 23. The intensity of the alkaline itching in the first case was reduced by the acidifying action of phosphoric acid, while the acid itching of the second case was intensi¬ fied. In Figure 24, the response of a patient with alkaline itching to the administration of sodium bicarbonate is shown. The intensity of itching was greatly increased after the alkalizing agent was given.

Fig. 23. Itching with an alkaline pattern is reduced in intensity by the administration of an acidifying agent. In the above example, two doses, each of 1.5 cc phosphoric acid (50%), were necessary in order to obtain this effect.

The fact that both pathological pain and pathological itching undergo the same changes in intensity related to the general acid-base balance would indicate that a similar mechanism may be involved in the pathogenesis of both symptoms. It can be conceived that a slight local pH change confined to the skin or mucous membrane could act on the itching end organs and

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

66

/

RBSEARCH

IN

PHYSIOPATHOLOOY

evoke the sensation of itching. More intense pH would result in pain. The fact that itching, one of the principal symptoms of dermatological condi¬ tions, can be related to local acid and alkaline changes within the skin would permit the integration of skin pathology in a more general physiopathological mechanism. The concept of the intervention of two different

Hour Fio. 24. The administration of 4 grams of sodium bicarbonate to a subject with an alkaline pattern of itching induces together with the alkalinization of the urine, ex¬ acerbation of the symptom.

abnormal processes, one resulting in acid substances and the other in alka¬ line compounds, represents a new approach to the study of many skin conditions. The therapeutic application of this concept has produced inter¬ esting results. (See Chapter XIV)

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

DUALISM

/

67

Vertigo Vertigo has been of special interest in our research. While it can be induced by various etiological factors, a basic dualism in its pathogenesis is evident. Many patients with vertigo have been found to experience wide varia¬ tions in the intensity of the symptom. Some have exacerbations in the morning, others in the evening. This observation suggested a possible dual pattern and we investigated vertigo by the same method used for the study of pathological pain. In patients with vertigo, the intensity was determined at hourly inter¬ vals by using either a scale ranging from 0 to 10, or a series of qualifica-

Fig. 25. Shows the curves of the intensity of vertigo and of the urinary pH in a case with an alkaline pattern, the variations of the two curves being parallel. (B. Welt, AMA Archives of Otolaryngology, 58:273-300, 1953.)

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

68

/

RESEARCH

IN

PHYSIOPATHOLOGY

tions, such as none, slight, moderate, severe, very severe and unbearable. At the same intervals, urine samples were collected and their pH values measured. Data were plotted in curves having time as common abscissa. Here again, as for pain, two different correlations could be observed. In some cases, the two curves—one for intensity of vertigo, and the other for urinary pH level—showed parallel variations. (Fig. 25) The vertigo became more intense when the pH was high, and this was considered to be vertigo

Hours Fio. 26. Vertigo with an acid pattern. The symptom is more intensive when the urinary pH values are lower. (B. Welt AM A Archives of Otolaryngology, 58:273300, 1953.)

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

DUALISM

/

69

of an alkaline pattern. In other cases—of an acid pattern—vertigo was more intense with lower values of urinary pH. (Fig. 26) The acid-base pathogenesis of vertigo was further confirmed by the response to acidifying and alkalizing agents. B. Welt has widely in¬ vestigated vertigo by this method. He also has used the response to thera¬ peutic agents as a criterion for the pattern present. The administration of butanol, heptanol or unsaturated fatty alcohols was seen to induce an increase in the intensity of vertigo of acid pattern and a decrease in the

27. The analysis of the concomitant changes in the curve of the intensity of the auditive acuity and of the urinary pH shows opposite variations in a subject with impaired hearing. The opposite variations are especially manifest for some values— 2000 cycles in this case. This relationship corresponds to an acid pattern. (Courtesy of Dr. B. Welt) Fig.

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

70

/

RESEARCH

IN

P H Y S I O P A TH OLO G Y

alkaline type. Agents such as sodium thiosulfate have an opposite effect. The great similarity in the response of pain and vertigo to the same agents has established the role of acid-base changes in the pathogenesis of vertigo as well as the possibility of influencing these changes in order to relieve the symptom. These studies have shown that, in spite of the variety of etiological factors which can induce vertigo, the condition can be con¬ sidered, from the point of view of therapy, in terms of its dualistic patho¬ genesis. This has simplified the therapeutic approach, limiting it to a choice between only two groups of agents. We will see later how successful this approach has been in Welt’s hands.

Fig. 28. The administration of an acidifying agent—2 grams of monoammonium phosphate—induces a marked increase of the hearing acuity if the abnormality pres¬ ent corresponds to an alkaline pattern. Only minimal or no changes are seen to occur if a few drops of acetic acid are used as placebo. (Courtesy of Dr. B. Welt.)

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

Fio. 29. Alkaline pattern of hearing impairment corresponds to an increased hearing acuity following the administration of 2 grams of ammonium phosphate.

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

/

RESEARCH

IN

PHYSIOPATHOLOGY

Loss in uecibeis

72

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

dualism

/

73

Impaired Hearing In studying the various otological problems, B. Welt and I noted that many patients with impaired hearing experienced variations in auditive acuity at different times of the day, or even in conjunction with food in¬ take. This led us to investigate impaired hearing by the same method used for pain. (Fig. 27) We studied the influence of acidifying and alkalizing agents upon auditive acuity in cases of impaired hearing. Complete audiograms were obtained, employing differences of only two decibels between measurements and using all of the accepted frequen¬ cies for air and bone conduction. Audiograms were obtained in subjects

Loss in Decibels

before and after administration of acidifying agents, such as ammonium

Fio. 31. The administration of 2 grams of monoammonium phosphate induces a decrease in hearing acuity if the abnormal pattern is acid.

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

74

/

RESEARCH

IN

PHYSIOPATHOLOGY

chloride and ammonium monophosphate, and alkalizing agents such as sodium bicarbonate. In normal subjects, the audiograms showed little or no change. In subjects with impaired hearing, three types of responses were noted for any one agent. The audiogram was either not changed at all or an increase or decrease in acuity was seen. If a manifest increase in acuity

was obtained with one group of agents, an opposite effect was obtained when an agent of the opposite group was administered. Changes of at least 6 decibels were required before they were consid¬ ered to be induced by an agent. When changes of such intensity were ob¬ tained with an agent, it was invariably true that opposite changes would be obtained with an opposite agent. It was also true that the same responses

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

DUALISM

/

75

could be obtained in the same patient in repeated tests. This appears to be highly significant, indicating that the response was, in fact, correlated with changes induced by the administered agent, changes similar to those seen in the case of acid-base symptoms. It was thus possible to integrate hearing impairment in the group of acid-base symptoms and to recognize two well-defined types, one corresponding to an acid pattern, the other to an alkaline. Figures 28 through 32 illustrate several cases taken from Welt’s observation. It must be noted that changes under the influence of the agents are seen at almost all frequencies in some cases but at only certain frequencies in others. It must be noted also that not all cases of impaired hearing could be placed in one or the other category. While this could be done almost with¬ out exception for young subjects or for those with still evolving conditions, it could not be done for subjects with old, fully evoluted impairment. It appears that once the pathological processes have arrived at a terminal point—and an inactive sclerotic scar is present—a response to acidifying or alkalizing agents is no longer to be expected.

Manic-depressive Condition We have studied the relationship between intensity of manifestations and systemic acid-base balance of the body in another group of subjects with various mental disorders. Of all the cases studied, the only condition in which a clear relationship could be shown was in manic-depressive sub¬ jects. From patients presenting changes during the day, passing from periods of high excitation to calm, from deep depression to calm, we ob¬ tained hourly urine specimens. At the same time, observations of their mental state were made. The evaluations of mental condition were made by trained observers or members of the family using a conventional scale which permitted translation into graph. The pH of the urine samples was measured electrometrically. Curves of the pH and of the mental conditions were plotted having the common time as abscissa. A striking correlation between the two curves was found in the first investigations in manic pa¬ tients. With the pH of the urine at higher values, the patient was calm, while the more acid urine corresponded to periods of intensive agitation. Figure 33 shows an example. This correlation also could be demonstrated by administering acidifying and alkalizing substances to manic patients. Acidification through the ad¬ ministration of phosphoric acid was followed by a manifest increase in agitation while administration of an alkalizing agent—sodium bicarbonate

Digitized by

Google

UNIVERSITY OF MICHIGAN

76

/

RESEARCH

IN

PHYSIOPATHOLOGY

—was followed by a period of calm. An opposite but less evident correla¬ tion was seen for several depressed patients. We must mention that the usual difficulty of judging accurately the degree of depression from one hour to another can explain this lesser correlation. Manic manifestations were much more readily evaluated.

o

i

^

3

H

*

*

7

Hours Fio. 33. The variations of the curve of the agitation of a 10-year-old boy are oppo¬ site to that of the urinary pH, indicating an acid pattern.

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

DUALISM

/

77

Dyspnea Certain characteristics of dyspnea suggested that this symptom might be explored by the same means employed in studying pain associated with path¬ ological tissue changes. A regular pattern is observed in certain types of dyspnea related to the time of day. Cardiac asthma or paroxysmal cardiac dyspnea occur mainly at night after patients have gone to sleep. However, this is not due to the recumbent position since patients may assume this position during the day without any ill effect. Harrison’s “evening dyspnea’’ (20) is characteristically absent in the morning, but develops slowly dur¬ ing the course of the day, reaching a maximum in the evening. Just as for pain, the degree of intensity of dyspnea was studied in rela¬ tion to hourly acid-base balance changes as indicated by changes in the pH of the urine. Patients having dyspnea of prolonged duration as a result of various pathological conditions, with no treatment of any kind for at least six hours before or during the period of observation, were the subjects of this investigation. The degree of intensity of the dyspnea was estimated by trained observers who were in constant attendance. Dyspnea was recorded by the observers as absent, slight, moderate, severe, or very severe, estima¬ tions being based upon rate depth and evident difficulty in respiration. At the time of these observations, hourly urine specimens were ob¬ tained from patients with as little disturbance as possible. No patient showed evidence of renal disease. The pH of the urine specimen was de¬ termined potentiometrically. The curves showing hourly fluctuations in the intensity of the dyspnea and the changes in the pH of the hourly urine specimens were then plotted and compared. Acidifying and alkalizing sub¬ stances were administered to patients during the course of some tests in order to observe the influence of induced changes in the acid-base balance upon the degree of dyspnea. Phosphoric acid and sodium bicarbonate were used for this purpose. Fourteen patients with different pathological conditions were studied. In ten cases, a distinct correlation between the intensity of the symptom and acid-base variations was found. Four patients had pulmonary edema associated with the symptom of dyspnea. One patient had edema due to congestive heart failure; another had pulmonary edema and lung metastases from a carcinoma of the pan¬ creas. Two other patients with cancer of the breast metastatic to the bone and skin also had pulmonary edema. In one of these, the pulmonary edema appeared to be a result of the accidental introduction of a fatty acid in oil preparation into the blood stream following an intramuscular injection. In

Digitized b

Google

UNIVERSITY OF

ICHIGAN

78

/

RESEARCH

IN

P H Y S IO P A TH O L OG Y

all four of the cases with pulmonary edema, the intensity of dyspnea was found to be increased when the urinary pH showed changes toward more alkaline values and was diminished when the pH changes were opposite. In these cases, the intensity of the dyspnea was relieved following admin-

Hour Fio. 34. The parallel variations between the curves of the intensity of dyspnea and of the value of the urinary pH in a case of pulmonary congestion following an accidental intravenous injection of a fatty acid preparation, indicates an alkaline pattern.

istration of phosphoric acid, while sodium bicarbonate increased the dysp¬ nea. By analogy with pain, we called this correlation an alkaline pattern.

(Fig. 34) Six cases showed an opposite type of correlation between the intensity of dyspnea and the acid-base changes in the pH of the urine. All of these

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

DUALISM

/

79

cases had mediastinal or pulmonary masses and failed to show signs of pulmonary edema. In these cases, the maximum degree of dyspnea was associated with a relatively more acid urine, and the dyspnea was less intense when the urine was more alkaline. In these cases, phosphoric acid increased the degree of dyspnea, while conversely sodium bicarbonate de¬ creased it. This would correspond to an acid pattern of dyspnea. (Figs. 35, 36)

These findings, although obtained in only a limited number of patients, strongly suggest a similarity between the fundamental origin of both pain and dyspnea. As in pain, the two patterns of dyspnea were associated with a relative alkalosis and a relative acidosis.

Hour Fig. 35. The opposite concomitant variations between the intensity of dyspnea and urinary pH in a case of mediastinal metastases of a hypernephroma indicate an acid pattern.

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

80

/

RESEARCH

IN

P H Y S IOP A TH OLOO Y

Certain differences exist between the investigations of pain and dysp¬ nea. In studying pain, it was necessary to depend entirely upon the ob¬ servations of the patient as to the relative intensity of the pain experienced from hour to hour. In dyspnea, the patient’s own observations were found

Hour Fig. 36. The administration of sodium bicarbonate increases the intensity of the dyspnea in a case of pulmonary metastases of cancer of the gall-bladder, indicating an alkaline pattern.

to be less reliable due to the emotional factors associated with dyspnea. It was, however, possible to depend upon trained observers who could estimate accurately enough the degree of dyspnea on the basis of rate, depth and apparent difficulty of respiration. It was found that the greater the experience of the observer, the closer was the correlation between the curves of intensity of dyspnea and the changes of the urinary pH values.

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

DUALISM

/

81

Since it appeared evident that acid-base changes play a significant role in influencing the degree of dyspnea experienced by the patient in two opposite directions, it was important to consider this influence in relation to the physiology of respiration which is known not only to be affected by, but even dependent on acid-base changes. Concerning the respiratory center, two different mechanisms of direct chemical stimulation have been suggested as being responsible for dyspnea. One is lack of oxygen, but considerable evidence exists to indicate that simple anoxemia is not a true cause of dyspnea. (21, 22) On the other hand, an acidosis of the respiratory center is known to cause dyspnea, but it has been established that only a very profound general acidosis, such as that connected with diabetes, acid poisoning or emphysema can create a change in blood pH sufficient to affect the respiratory center. This is also true for the chemoreceptor centers located in the carotid sinus, which are still less sensitive to the general lack of oxygen or acidosis than the respira¬ tory center. While general acid-base changes seem to play an important role in dyspnea, these chemical changes would not appear to act directly upon the respiratory center since the actual blood pH is not sufficiently changed. Other factors—involving direct local, rather than systemic influences— may be considered. One such direct action would be related to reflex stimu¬ lation which is generally accepted as having an important role in the control of respiration and even dyspnea. This reflex control of respiration is connected with nerve endings within the lung parenchyma which are stimulated when the walls of the alveoli are stretched in the respiratory phase. The stretch reflex induces impulses, carried by way of the vagus, which acting upon the respiratory center, stop the inspiratory phase and bring about expiration. It may be assumed that the nerve endings within the parenchyma can be stimulated not only by mechanical changes within the parenchyma but also by local chemical changes too. Under abnormal conditions such as pulmonary congestion, there may be a change in the tissue reaction, as has been recognized by a higher pH of the edema fluid itself. Through this reflex mechanism, these pulmonary tissue reaction changes may produce dyspnea. The general acid-base fluctuations influenc¬ ing the local alkalosis would, as seen in pain, indirectly influence the degree of dyspnea. Such a mechanism may account for dyspnea with an alkaline pattern found in pulmonary congestion. A similar local factor also could be seen for the acid pattern. It was observed that all patients with an acid pattern of dyspnea had tumors located within the mediastinum or in the lung parenchyma itself. From

Google

UNIVERSITY OF MICHIGAN

82

/

RESEARCH

IN

PHYSIOPATHOLOGY

the study of pain, we know that abnormal degrees of acidosis can occur in tumors. pH changes toward acidosis within a tumor tissue in the vicinity of chemoreceptors may produce impulse discharges in these centers espe¬ cially sensitive to changes toward acidosis. They may alter the character of respiration and result in dyspnea. As in other conditions, these local changes occur even with reduced changes in the systemic acid-base bal¬ ance. Through this mechanism, variations in the intensity of dyspnea can occur without the intensive change in the general acid-base balance which is considered necessary to affect directly the respiratory center itself. The fact that relatively small acid-base balance changes affect the in¬ tensity of dyspnea in two opposite directions can thus be explained by this indirect influence exerted upon a local process, leading to alkalosis in ab¬ normal conditions affecting the pulmonary parenchyma and to acidosis in lesions present in the neighborhood of the chemoreceptive centers. These two mechanisms proposed as part of this working hypothesis, appear able to explain the paradoxical experimental findings in clinical studies of this symptom, where opposite responses upon dyspnea are seen for the same acidifying and alkalizing agents. A more complete study of dyspnea under this aspect will be published separately.

Dualistic Patterns at Other Levels Cellular Level

Cytological studies have revealed that some characteristics of the cell, other than those typifying the cancerous anomaly itself, exhibit dual pat¬ terns. For the cellular level, they could ultimately be related to changes in the aging processes. In tumoral foci having an acid pain pattern, cytological characteristics indicate a prolonged cellular youth. A round aspect of the nucleus, with a fine texture of chromatin and well-separated nucleolus, and a basophyl cytoplasm represent major characteristics of cellular youth. In lesions with an alkaline pain pattern, the cells show rapid early aging. The tendency to lobulation of the nucleus, to separation of chromatin and formation of clumps, to cytoplasmatic oxyphily and the appearance of azurophyl granulae characterize such aging. Rapid aging was seen to lead to premature cellular death through piknosis and karyorrhexis. Opposite cellular aging processes could be further related to differences seen in evo¬ lution of tumors. Rapid aging of cells, associated with alkaline pain pat¬ terns, results in necrotic tumors and ulceration of superficial lesions. Frequently, it could be noted that a change from acid pattern to alkaline

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

DUALISM

/

83

occurs and is accompanied by a melting away of massive tumors and their replacement usually by ulceration. Tissular Level As seen above, pain, dyspnea, vertigo and itching can be considered tissue level manifestations which show dualism. Additionally, the nasal pH (Note 5) deviates either toward acid or alkaline values and these devia¬ tions can be correlated with similar acid-base changes at the tissular level. These measurements are useful as a diagnostic criterion for tissue level changes. Organic Level The same dualism observed at the cellular and tissue levels also was found in signs and symptoms involving the organ level. Dual patterns were found for dysfunctions of various organs. Insomnia and somnolence, diar¬ rhea and constipation, oliguria and polyuria, tachycardia and bradycardia, all represent examples of dualism at the organic level. The dualism evident for the length of persistence of a wheal (Note 6) induced by intracutaneous injection of a saline solution was also related to the organ level with the skin considered to be an organ. In normal sub¬ jects, the resorption of the wheal is completed in about 15-20 minutes. In one group the resorption time is short, even reduced to a few minutes. In other groups, on the contrary, the resorption time is greatly prolonged, the wheal sometimes being present even after more than 90 minutes. Systemic Level Studies of dualism at this level covered temperature variations and changes in various blood and urine values. Temperature Two patterns of temperature changes were found in cancer patients. For oral temperature, 37°C (98.6°F) was considered as the reference value. Temperatures measured several times during the day showed that, for many patients, the values were fixed either above or below this refer¬ ence line. Normal individuals exhibit daily variations of temperature; the curve not only crosses the reference line but also shows broad changes. In contrast, variations usually are smaller in abnormal cases, and the curve remains on one or the other side of the reference line. Figures 37, 38 and 39 show examples of such curves. The two patterns have been found to be

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

Fig. 37. The curve of oral temperature of a case with generalized metastatic mela¬ noma is persistently above the 98.6#F (37*C) line, which corresponds to the av¬ erage value of normal individuals.

Fig. 38. The curve of the oral temperature of a patient with generalized metastases of adenocarcinoma of the breast shows values constantly below the 98.6*F average line.

Digitize 11 n

Google

Original from

UNIVERSITY OF MICHIGAN

DUALISM

/

85

Fig. 39. Curve of the oral temperature of a patient with bronchogenic cancer with abdominal metastases shows values constantly below 98.6°F (37°C) average line.

independent of type or site of origin of tumors. We will discuss the signifi¬ cance of temperature patterns later. Systemic Analyses: Changes in urine or blood values were followed in hundreds of subjects for long periods, even years. It appeared essential to plot the data graph¬ ically. An average value, obtained from a significant number of normal subjects, was represented in graphs as a reference line. In normal subjects, as a general rule, relatively wide oscillations occur around the average value line. By contrast, in disease states, there is a fixation of the curve on one or the other side of the average value, the curves exhibiting only slight, or even no, variations. Two opposing patterns are thus evident in disease states for each type of analysis of blood and urine. The dualism indicates once again the existence in systemic metabolism of two kinds of abnormal changes with antagonistic characteristics. It is important to note that the advanced cancerous condition is characterized by a marked dualistic pat¬ tern at the systemic level.

Google

Original *rom

UNIVERSITY OF MICHIGAN

86

/

RESEARCH

IN

PH YSIOP ATHOLOOY

Blood In blood analyses, the concentrations of potassium and calcium, the presence of C reactive proteins, the number of leucocytes and of circulat¬ ing eosinophiles, (Note 7) and the red cell sedimentation rate, have been studied, using classical methods. They all show the same dualism. Figs. 40 to 43 show some of these curves with the average values as reference lines. With the intention of obtaining information concerning the amount of potassium present in cells, we investigated the content of this cation of the red cells. (Note 8) Urine In urine studies, measurements were made for pH, specific gravity, surface tension, oxido-reduction potential, excretion of sodium, potassium, calcium, chlorides, phosphates, sulfates, sulfhydryl, indoxyl, glucuronic acid, peroxides, etc. Most studies were carried out by routine test tech¬ niques. For some analyses, however, conventional techniques were found to be inadequate and new tests devised. For the urinary excretion of sulfhydryl, a new technique was devised by M. Bier and P. Teitelbaum in our laboratories. Using the Warburg micromanometer, the nitrogen liberated from sodium azide in a buffered solution in the presence of free iodine was found to be directly related to the amount of sulfhydryl present. The amount of nitrogen freed at a deter¬ mined moment—13 minutes—was most indicative. (Note 9) For the information which we needed concerning the amount of cal¬ cium in urine a very simple method was devised. (Note 10) For measurement of urinary surface tension, we devised a new technique. We used a capillary so calibrated as to give the surface tension in dyne/cm for a fluid with a specific gravity of 1.015. In this method, several arrests or slowdowns of the descending column are noted and make it possible to obtain information about an extremely important factor which is usually not considered in the measurement of surface tension with other methods. It is known that urine is formed of different constituents, some of them with the tendency to move toward the surface while others tend to move toward the bulk of the fluid. Changes in the distribution of these constituents take place. They induce changes in the value of the surface tension of the urine which occur even during the time measurements are taken. The descending column in a capillary will indicate these changes which are important for precise measurement of surface tension of urine. (Note 11)

Original from Digitized by uuo

UNIVERSITY OF MICHIGAN

DUALISM

/

87

Fig. 40. Curve of the value of the /C+ in blood serum in a case with periarteritis nodosa. The values remain above 4.5 mEq, which represent the average value ob¬ tained from series of normals.

Fio. 41. Curve of the values of K+ in the blood serum of a subject with carcinoma of the breast, liver metastases and jaundice. The values remain almost constantly be¬ low the 4.5 mEq line.

Digitized by

Goo

Onginal from

UNIVERSITY OF MICHIGAN

/

RESEARCH

IN

PH YSIOP ATHOLOGY

). 42. The curve of the number of blood leucocytes of a case of breast adenocinoma shows constantly values above 7.000, considered as the average value for nnals.

Leucocytes

g 8 3

Leucocytes

88

Fio. 43. The curve of the number of blood leucocytes of a case of breast carcinoma shows persistently values below the average line of 7.000.

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

DUALISM

/

89

Two methods were employed to measure the oxido-reduction potential of urine. In one, the measurement was made with a potentiometer using a platinum electrode, first at the pH of the urine and once again after bring¬ ing the pH to 7 by adding the necessary amount of NaOH or HC1. (Note 12) In the second technique, differences in potential were measured through the time necessary to discolor a solution of tduidine blue in an acid medium at 100°C. The value was determined in seconds, the concentra¬ tion of the dye having been chosen so that discoloration in 100 seconds represented an average value for normal subjects. More rapid discoloration indicated higher potential, while a low potential corresponded to slow or even no discoloration. (Note 13) The presence and relative amounts of oxydizing substances in the urine were also investigated by means of two reactions: in one, through the pas¬ sage of indoxyl into indigotine and indigorubine under the influence of sulfuric acid (Note 14); in the other, through liberation of iodine from iodides in the acid medium. It is interesting to mention at this moment, the variations encountered in the metabolism of nitrogen and the form under which it is excreted through the kidney under normal and pathological conditions. We could show that in general the form of excretion is determined by the amount of water also excreted by the organism. High amounts of water will thus induce the excretion of nitrogen principally as ammonia, low amounts as uric acid. This relationship was explained by data found in comparative physiology. The availability of water in the environment of various animals was seen to determine the form under which these animals excrete nitrogen. The occur¬ rence of similar conditions concerning the excretion of water in pathological states, furnishes an interesting explanation for the form under which it is ex¬ creted in these pathological conditions. In Note 15 this problem is discussed in more details. In all tests requiring quantitative measurements, an important problem arose. It appeared practically impossible to obtain 24 hour urines routinely for periods of months in large groups of individuals in order to note the continuous changes in excretion of the different substances studied. Meas¬ urements of various substances eliminated in urine could be made under these circumstances only by using isolated samples. The values so obtained express the concentrations of the substances in the sample and consequently were directly related not only to the amount eliminated by the kidney but also to the amount of water excreted at the same time. The values varied greatly from one specimen to the next, according to the amount of water excreted. Therefore these data could only be of relative usefulness. Since

Digitized by GOOgk

UNIVERSITY OF MICHIGAN

90

/

RESEARCH

IN

PHYSIOPATHOLOOY

specific gravity is also a direct function of the amount of water excreted in a urine sample, we related the concentration of a substance to the specific gravity of the same sample. This ratio provided a new value which is in¬ dependent of the amount of water in the sample and is more closely re¬ lated to the amount of the other substances which vary much less in amount than water. From the physiopathological point of view, the data obtained were seen to correspond to the degree of active reabsorption of a given substance by the kidney. While the ratio of the concentration over specific gravity would vary directly with the excretion of the substance, the inverse ratio would represent an index of retention, which increases with the reten¬ tion of the substance in the body. Such indices were routinely applied for the different substances tested in urine to obtain more reliable values than could be obtained from the concentration data alone. (Note 15) Urinary Patterns Various urinalyses were performed during sufficient lengths of time on a larger number of subjects considered to be normal. For each test, an average value was thus obtained. This average value served as a reference line for the curves traced with the data obtained from the subjects. The

Fio. 44. Curves of different analyses of daily urine samples of a normal 40-yearold male. For each kind of analysis, the corresponding average value was calculated from the measurements obtained in more than one hundred normal subjects. The curves are seen to pass from one to the other side of the lines corresponding to the respective average values. A certain correspondence is seen for the changes which take place at the same time in these curves. Parallel variations are seen between spe¬ cific gravity and chloride index, while opposite to those for the pH and surface tension.

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

DUALISM

/

91

study of these curves has permitted us to recognize several characteristic patterns. Under conditions considered normal, the curves were seen to pass from one side to the other on this average line with relatively wide varia¬ tions. When an abnormality existed, the various urine analyses were char¬ acterized by a curve with only small variations, fixed on one or the other side of the average line. For each test, two such characteristic abnormal patterns are encountered. Fig. 44 shows the curves of different tests passing

Fio. 45. Curves of the values of the urinary pH followed during 50 days in five subjects. The curve (a) corresponds to a normal individual while the other four (b, c, d, e) to subjects with different cancerous lesions. For the normal case, the values pass above and below the 6.2 value which is considered as the average com¬ puted values obtained from normals. For the abnormal cases, the curves which show little variations are fixed at one or the other side of the average line. For case (b), an adenocarcinoma of the ovary, and case (c), a bronchogenic cancer, the curves are fixed below the average line. For case (d), with a bronchogenic cancer, and case (e), a cancer of the breast with generalized metastases, the curves are above this average line.

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

DUALISM

June

/

93

July

15

20

25

30

5

Patient- Mr Spe. Fig. 47. Curve of the values of the urinary specific gravity in a case of cancer of the breast, with the values fixed above 1016 which is considered as an average value for the specific gravity as computed from a series of measurements in normals.

from one sick to the other of the respective average lines as corresponding to a normal subject. Figures 45 to 51 show several examples of two opposite patterns for the various tests used such as urinary pH, specific gravity, sur¬ face tension, chloride index and sulfhydryl index. Fundamental Offbalances When the curves of various analyses obtained at the same time for the same subject were checked, an interesting relationship was found. In patients with small localized tumors, only some of the analyses showed abnormal patterns. However, with the evolution of cancer toward the terminal stage, abnormal patterns became apparent for more and more analyses. In advanced cases, most of the analyses showed abnormal pat¬ terns.

Moy

10

15

20

25

Fig. 48. The values of the urinary specific gravity in a case of cancer of the breast, are the whole time below the average value of 1016.

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

94

/

RESEARCH

IN

PHYSIOPATHOLOGY

Sulfhydryl Index

Fio. 49. The urinary surface tension remains constantly fixed above the average value of 68 for more than a year in a case of cancer of the urethra.

Days Fig. 50. The urinary sulfhydryl index remains below the average value of 1.5, in a case of cancer of the breast, with bone metastases.

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

DUALISM

/

95

It was especially in advanced stages that definite groupings of patterns with opposite characteristics could be recognized. They corresponded to two fundamental offbalances which we have called “Type A” and “Type D.” (“A” for anoxybiosis, “D” for dysoxybiosis which represent the prin¬ cipal manifestations of oxygen metabolism in a phase of these offbalances.) The correspondence between the different abnormal patterns defining the offbalance A or D, is seen in Figures 52 to 60. The abnormal pattern of

Fig. 51. The urinary sulfhydryl index remains above the average value of 1.5 in a case of hypernephroma with lung metastases.

the low urinary specific gravity appears together with a pattern of high values for the pH, both corresponding to the offbalance type A. (Fig. 52) A high urinary pH and low chloride index pattern correspond to the offbalance type A, as seen in Fig. 53. The analyses of a case with low specific gravity, high pH, low chloride index and high surface tension, as present in offbalance type A, is shown in Fig. 54. An opposite case, offbalance type D, with high specific gravity, low pH, high chloride index and low surface tension is shown in Fig. 55. A similar case of offbalance type D is shown in Fig. 56 with high urinary specific gravity, low pH, low surface tension and low blood leucocyte number. In Fig. 57, the low pH, high sulfhydryl index and low surface tension show an offbalance of the type D. The independence of the levels may explain why, in the same subject,

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

96

/

RESEARCH

IN

PHYSIOPATHOLOGY

1941 May

June

Fw. 52. A correspondence is seen between the patterns of urinary specific gravity and that of the urinary pH in a cancer of the colon corresponding to the type A offbalance. The changes still present in the curves are opposite.

not all the analytical patterns obligatory concord at all times in the same subject. Especially when defense reactions intervene, the offbalance at one level can be different from that at other levels. Fig. 58 shows such examples. Usually, as the disease progresses, many of these differences disappear, the manifestations—analytical and clinical at different levels—entering in the same type of offbalance. Fig. 59 shows such an example.

Fig. 53. In a case of sarcoma of the leg with lung metastases the curve of the uri¬ nary pH is fixed above the average line (6.2) while the curve of chloride index be¬ low the average line of 2.5. This relationship indicates a type A of the offbalance.

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

DUALISM

r«br»or,

.5 .

r*

/

97

March

K>etOt9.3IOI»tO **■*'*» » — *■ * * ^ 1 * ^ *.«

Pbt** • KQ

Fig. 54. The analysis of a terminal case of cancer of the breast, showing the funda¬ mental offbalance, low specific gravity, high pH, low chloride index and high sur¬ face tension, corresponding thus to the offbalance A.

The passage of a subject from one offbalance into the opposite one is seen to occur during the evolution of the condition most often induced by thera¬ peutic attempts. Fig. 60 shows such an example. The two opposite offbalances, identified first through the urine analyses, could be recognized to exist for all the manifestations taking place at the different levels of the organization. The manifestations seen at these levels could thus be interpreted as corresponding to one of the two opposite fundamental offbalances, type A and D. Table IV shows this coordination of the different manifestations according to the two opposite offbalances. On the basis of all these data, clinical manifestations and analyses, the dualistic pathogenic concept appeared to be well established and the dual-

No*

Doc 30,

Jam

5

K>

m

fO

»

30.

»

Pof«ni A/m

Fig. 55. A terminal case of cancer of the breast shows all the analyses fixed in opposite position to the case of Fig. 54, i.e., high specific gravity, low pH, high chloride index and low surface tension, corresponding to an offbalance of the type D.

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

98

/

RESEARCH

IN

PHYSIOPATHOLOGY

Fio. 56. Offbalance type D, shows high urine specific gravity, low pH, low surface tension and low blood leucocyte number.

66 iH

5* 6o

=

SA

oo

So

X3‘

rrrrrrT

71 /i mi

JMC.

10 11 +1 !•> *e> ft II

& l

J

4

*

o'

Days

Fig. 57. The 3 curves, pH, sulfhydryl index and surface tension show an offbalance type D.

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

DUALISM

/

99

istic physiopathological mechanism studied in complex conditions in general and in cancer in particular.

Jon

»

ftb

5

C

15

7Q

3

Morcn

5

tO

IS

20

Fig. 58. The urine analyses of a patient with cancer of the ovary, showing a dis¬ cordance between the patterns present. While all the analyses show patterns of the type D, the chloride index remains throughout the entire observation constantly of type A.

Place of Dualism in Cancer Physiopathology After recognizing a dual pattern in most manifestations of cancer, the problem was to consider the relationship between this dualism and cancer itself. One critical observation was that a pattern in a given patient may change. During the evolution of the condition, seldom is the change from abnormal to normal, but usually from one abnormal to the opposite ab¬ normal pattern. This fact has a special importance as will be seen later. In some cases, even the immediate, direct cause of such changes could be established. The following case is illustrative. Mr. S. L., a patient with cancer of the prostate and metastatic destruc¬ tion of half of the sacrum, was in very severe pain. Study of variations in pain intensity and in urinary pH, as well as the response to acidifying and alkalinizing substances, indicated that the pain was of a typical acid pat¬ tern. The patient started radiotherapy and pain decreased with almost every treatment, until after a few sessions it had disappeared completely. Out of bed and feeling well, he continued the treatment. However, at about the twelfth session, pain again appeared and thereafter increased with each treatment. After five more sessions, he was back in bed and suffering such unbearable pain that radiotherapy had to be discontinued. At that time, a new analysis of the pattern of pain showed that it had changed from the original acid to alkaline. It was hypothesized that this change might be the

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

°glc

UNIVERSITY OF MICHIGAN

138

/

RESEARCH

IN

P HYS I OP ATH OLOOY

steroids has permitted us to recognize the conditions which induce stronger activity for these polar groups, conditions which are usually fulfilled in the naturally occurring members. It could thus be seen that the reactivity of an oxygen bound to C3 is increased if another double bond present in the cycle is parallel to the double bond through which the oxygen is bound to C8. A double bond between C4 and C3, as shown in Figure 64 (a), fulfills

Fio. 64. Influence exerted upon the oxygen bond at C« by the position of the double bond in the cycles 1 and 2 of the cyclopentanephenanthrene molecule. A parallelism between the double bond of oxygen and that present between C. and C. increases the energetic character of the carbonyl (a). A similar influence but less active, is ex¬ erted by the double bond between C. and Cr. A double bond added between Ci and C* (c) increases the activity. Still more activity would result from a third double bond added between C« and Ct (d).

such a condition. A similar influence is exerted indirectly by a double bond between Cfl and C7 (b) which, through induction, will influence the parallel C4 and C3 bond and further the double bond of the oxygen. This explains the influence exerted by the double bond present between Cx and C2 (c), as in the synthetic, prednisolone. Further enhancement of reactivity would be obtained with a third double bond added between C« and C7. The paral¬ lelism between three double bonds (d)

would produce an increased

reactivity. For the hydroxyl, a similar enhanced reactivity is induced by double bonding of the carbon to which the hydroxyl is attached with a double bond for the C3 — C4 or Q* — C3, as shown in Figure 65 (a and b). A similar condition is fulfilled if a double bond is present in the molecule parallel to any of these bonds, as seen in Figure 65 (c) where the double

Fio. 65. The influence exerted upon the hydroxyl bond at Ci by a double bond in the cycle 1 and 2 of the phenanthrene is increased if the double bond is adjacent or parallel to the bonds of C*. bearing the hydroxyl.

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

LIPIDS

AND

LIPOIDS

/

139

bond is between C5 and C8. An enhanced reactivity of these compounds would be obtained with one double bond between C8 and C4 and another between C5 and Cfl (d). We will come back to this important intervention of the double bonds in cyclic molecules. The energetic property of the cyclopentane group appears to be corre¬ lated with its odd number of carbons. The alternate succession of carbons with positive and negative characters resulting from the induction effect causes two carbons of this cycle to have the same sign. This “twin forma¬ tion” induces a special molecular reactivity related to the pentanic cycle of the steroid molecule. (Note 9) The special reactivity seen for C8 of the cyclopentanophenanthrene molecule can be explained through a hypothesis covering the origin of these substances. Although the origin of a cholesterol molecule through a cyclization of squalene (35) appears plausible, this seems less probable for the corticoids. We have tried to connect their origin to arachidonic acid. Several considerations such as the high levels of arachidonic acid and corticoids in the adrenals, and the reduction of the former when an im¬ portant amount of the latter is excreted (Note 10), seem to establish a correlation between these substances. According to our hypothesis, the steroids with a two carbon chain at Ci7, as seen present in the corticoids and luteoids, would result from a cyclization of the arachidonic molecule. (Note 11) This would explain the special reactivity of C8, which would correspond to C® of the arachidonic acid bound in this molecule by a double bond. A study of the different steroids under this energetic aspect has per¬ mitted us to understand their physiologic properties. With the C8 having a hydroxyl or an oxygen as polar group in almost all the steroids, the variety of the biological properties would be related to the different conditions at the other extremity of the molecule, principally at C17f which result from the special energetic conditions prevalent at this region of the molecule. The simplest steroids are those having a polar group represented by an OH or O fixed at Ci7. Such naturally occurring steroids have properties related to secondary sex characteristics. We will discuss them briefly here. Sex Hormones This group of steroids has two polar groups, one at C8 and one at Ci7. The energetic center at C8 can have negative or positive polar characters, according to the presence of oxygen or hydroxyl. The energetic center at

Digitized by

Google

UNIVERSITY OF MICHIGAN

140

/

RESEARCH

IN

P H Y S I O P A TH O L OG Y

On also can have an oxygen or hydroxyl group and thus be negative or positive. An important factor for the properties of the substance is the relationship between the two polar groups in the same molecule. It is ap¬ parent that the polarity of the molecule will vary according to what polar groups are present at C3 and C17. In a very simplified concept, which we consider only partially accurate, we have tried to associate female and male hormonal characteristics with this polarity. In the simple steroid molecules, a folliculinoid or estrogenic biological property seems to be conferred if the two polar groups—at C8 and CJ7 —are formed by hydroxyls. The molecule appears to have a dipositive polarity. It seems to be important that the two hydroxyls be kept in the relatively fixed reciprocal positions—corresponding to C3 and C17—as part of the solid skeleton of the steroids. Estrogenic properties are present in various steroids that fulfill this condition. Furthermore, substances far removed from the steroids have folliculinoid properties if they have this relationship between the two hydroxyls. As shown in Figure 66 diethylstilbestrol, which has its two hydroxyls maintained in a fixed relative posi¬ tion similar to that of steroid estrogens, also shows potent estrogenic activity.

Estradiol

Diethylstilbestrol

Fio. 66. The folliculinoid activity appears to be related to the existence of two hydroxyls kept at the same relative position, as it appears in estradiol and in diethyl¬ stilbestrol.

In the same way, we tried to correlate testoid activity with the presence of positive-negative polarity; that is, with two polar centers energetically different, one corresponding to an oxygen and the other to a hydroxyl, maintained in the same fixed relative position. The importance of this relative steric position of the two polar groups for testoid activity becomes evident when it is found in substances other than testosterone, the principal male hormone, with an oxygen at C3 and a hydroxyl at C17. Testoid activ¬ ity is present in androsterone, which has an oxygen and an hydroxyl main¬ tained in the same reciprocal positions, although here the oxygen is at C]7

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

LIPIDS

AND

LIPOIDS

/

141

and the hydroxyl at C3, the reverse of testosterone. In both substances, testosterone and androsterone, the two conditions for testoid activity, posi¬ tive-negative polarity and the same relative position between the polar groups, are fulfilled. (Fig. 67) The differences which exist between these substances in their specific hormonal activity can be explained through the different influence exerted upon the two polar groups in these substances by the rest of the molecules.

Testosterone

Androsterone

67. The testoid activity seems to be related to the presence of a hydroxyl and a carbonyl in the same fixed relative position which is insured by the rigidity of the steroid molecule. The same positional reciprocal relationship is seen to exist between these two polar groups in testosterone and androsterone. Fig.

The testoid activity seen for cortisone, hydrocortisone and other hor¬ mones also can be explained by the presence in these molecules of oxygen and hydroxyl at C3 and C17, and maintenance of the fixed position between these two polar groups. Conceptually, the antagonism between estrogenic and testoid biological activities can be considered to be ultimately related to the differences in polarity, which in one form or another can be found in other factors differ¬ ing for the sexes. We will mention here only that a similar difference be¬ tween male and female character is seen in the sexual chromosomes, where the female character is related to the XX chromosome, and the male to an X and a Y chromosome. As we will see below, a relationship exists between lipids in general and sex. Besides the sex hormones, fatty acids appear to be connected with male sex characteristics, while female characteristics are related to another group of steroids, the sterols.

Characteristic of the structure of this group of steroids is the presence of a hydroxyl at C8 and a long chain bond at CI7. Through the hydroxyl,

Digitized by

Google

Original rrom

UNIVERSITY OF MICHIGAN

142

/

RESEARCH

IN

PHYSIOPATHOLOGY

the center at C8 has a nucleophilic character. This is reinforced by the presence of a double bond between C5 and Ca which, by paralleling the bond between C8 and C4> increases its ionic character and consequently the reactivity of the hydroxyl bond to Cs. Through this hydroxyl, sterols combine in general with substances having a negative polar group to form esters. Besides the capacity to combine with fatty acids in general, one of the most important characteristics of the principal sterol of animals, choles¬ terol, is its selective affinity for certain fatty acid members, the polyunsatu¬ rated. We tried to explain the specificity of this bond through an interesting process which could be called “steric coupling.” In this process, two molecules, usually lipoids, are kept together not only by the combination of their polar groups but also through a bond between their nonpolar parts. The two molecules are reciprocally attracted through the multiple forces present in the nonpolar groups. Some are re¬ lated to attached centers, while some, such as those corresponding to cohesion forces, are related to the rings themselves. An important factor is the rigidity of the sterol molecule which permits another molecule, if it is flexible, to make the steric coupling. The rigid skeleton not only keeps the energetic centers of one molecule in a fixed position but permits the flexible aliphatic chain to cover over the polycyclic molecule and thus bring the energetic centers of one molecule in contact with those of the other. Through this, steric coupling completes the bonding of the polar groups. The greater the concordance between energetic centers in both molecules, the more perfect the coupling is, for the more complete is the reciprocal neutralization of the energetic centers of the two molecules. Steric coupling explains why, of all the fatty acids present in the organism, cholesterol seems to prefer to bind those with polyunsaturated chains. It is these fatty acids which have several energetic centers in the nonpolar group as repre¬ sented by double bonds. The long chains of these fatty acid molecules, having a certain degree of flexibility, will then complete the steric coupling. (Note 12) Steric coupling, in addition to its general importance in biology, where it represents a kind of molecular reactivity, seems to explain the antago¬ nistic influence exercised by different constituents, especially the sterols and polyunsaturated fatty acids. Through steric coupling, cholesterol could influence the activity of these fatty acids more directly related to the non¬ polar group. It has to be emphasized, however, that the neutralization resulting from steric coupling is not irreversible. On the contrary, through the intervention of various factors, such as the breaking down of the bond

Google

unainai from UNIVERSITY OF MICHIGAN

LIPIDS

AND

LIPOIDS

/

143

between the polar groups, the two coupled molecules can regain their inde¬ pendence. This would explain the relative lability of the combinations be¬ tween fatty acids and sterols. The antagonism between fatty acids and sterols is an important aspect of biological dualism which will be discussed in more detail later when these substances are studied in terms of their influence at the different levels of organization.

Steroids with a Two-Carbon Chain Among the most important steroids are those having a two-carbon chain fixed at C17. Two groups, the luteoids and corticoids, appear directly related to allopregnane hydrocarbon, the steroid polycycle with a two-carbon lateral chain fixed at Ci7. As we have already seen in the hypothesis concerning the origin of the steroids (Note 11), this hydrocarbon could have been di¬ rectly derived from arachidonic acid, the two-carbon lateral chain corre¬ sponding to the tail chain of this acid, a tail which remains after cyclization. The Luteoids The prototype of the luteoids is progesterone. Two polar groups C = O are present, one at C8 of the polycycle and the other at C20 of the tail chain. A parallel double bond between C4 and C3 completes the formula. Ener¬ getically, progesterone presents a first center at C8 which appears strongly nucleophilic for two reasons: first, because it corresponds to the potent electronegative C3 and second, because it is reinforced by a double bond present between C4 and C5, and which is hence parallel with the double bond of the carbonyl. The second = O is attached to the C20 of the tail chain. This also appears reinforced, the double bond of this carbonyl being parallel to the bond between the Cj3 and CJ7, which in the cyclopentane, accord¬ ing to the hypothesis of twin carbons, binds two negative charged carbons. Through its constitution progesterone is also a lipoid, the complex hydro¬ carbon group being predominant over the polar groups. With its polar nucleophilic centers, progesterone has the fundamental character of acid lipoids. Progesterone’s luteoid activity corresponds to the presence of two relatively strong neutrophilic centers kept in the characteristic positions, one at C3 and the other at C20. We can see that any disturbance in this energetic picture, any change from the dinucleophilic at any center, decreases the luteoid properties of the substance. With more profound changes, the luteoid activity is even suppressed. (Note 13)

Digitized by

Google

Original rrom

UNIVERSITY OF MICHIGAN

144

/

RESEARCH

IN

PHYSIOPATHOLOGY

Corticoids The corticoids represent the group of hormones upon which the atten¬ tion of scientists recently has been intensively focused because of their new therapeutic applications. Chemically, they appear to be the same as luteoids, derivatives of the same parent hydrocarbon, allopregnane. Structurally, all these adrenocorticoid hormones have: a) a C8 binding an O group; b) a double bond be¬ tween C4 and C5 in the first cycle; c) a two-carbon tail chain with an O attached in ketone form to C20; d) an OH as primary alcohol present at Cjj. This structure, common to all corticoids, seems to be responsible for the principal properties of these substances. Corticoids have been separated into subgroups based upon the presence of attached groups OH or = O at Cii or OH at Ci7. The presence or absence of attached radicals at Cn appears to be most important. Corticoids without attached radicals at the Cn have a major influence on the metabolism of electrolytes. The second group of corticoids, having the radical, are known as neoglucogenic corti¬ coids, the name indicating their principal biological characteristics. Energetically, the corticoids present a nucleophilic center at C8, reinforced by the presence of the double bond in the cycle between C4 and C5. The double bond is parallel to the double bond of the carboxyl, and thus inductively increases the ionic character of the latter. A second energetic group of the tail chain appears in toto as a strong tripolar center with a nucleophilic center at C20 of this chain and an electro¬ philic center at Cm- (Note 14) To this basic pattern is added, in the neoglucogenic corticoid, a separate energetic center at Cn, which can be either electrophilic, formed by a hydroxyl, or nucleophilic, formed by an oxygen. Corticoids appear, in general, to act as positive lipoids. (Note 15) Because of their importance in relation to anti-fatty acid activity, we will discuss first the neoglucogenic corticoids, the members with a polar group also at Cn. According to our hypothesis, these steroids have a spe¬ cial biological activity, a role in the process of synthesis in the organism. The part of the molecule between C,i and C2\ constitutes an energetic formation with a peculiar property. It represents a kind of energetic mold or template, in which each carbon has its specific energetic character. Dif¬ ferent radicals would be attracted by the energetic centers of this template formation according to their own energetic nature. Kept in their respective positions, they would be induced to bind together in order to form new substances. In this manner this template formation would promote new

Google

unainai rrom UNIVERSITY OF MICHIGAN

LIPIDS

AND

LIPOIDS

/

145

syntheses. In different corticoids the constitution of the Cn = Cai formation will differ and this will determine which substance is to be synthesized by the respective mold or template formation. (Note 16) Using the template hypothesis, we studied an entire series of body constituents forming the “gluco group.” Glucose, galactose, glucosamine and galactosamine, with their respective acids, as well as ascorbic acid, are among theses substances. According to our hypothesis, these neoglucogenic corticoids would have the important role of producing, possibly along with other mechanisms, the entire series of “gluco” constituents. The existence of different template formations would result in a variety of synthesized constituents. The intervention of the template formation in synthesis can occur again and again without affecting the molecule of the corticoid as such. It is interesting to note here a structural curiosity which could be interpreted as being related to template activity. In this template, the group of suc¬ cessive Cn, C12, Cis and Cn are part of the rigid skeleton of the cyclic molecule, while C20 and C2] are forming the lateral chain attached to Ci7. This can be regarded as conferring a certain proper mobility to this lateral chain as related to the polycycle. It is conceivable that this lateral chain would become a closed formation when synthesis takes place. A movement of the chain at Cu would permit the mold to open and thus liberate the synthesized molecule. It is interesting to note here the importance of the structure of the template for the constitution of the substances synthesized. Besides the polar group at Cj7, that at Cn is also important for neoglucogenic activity since it insures a six-carbon chain in the synthesized mole¬ cules. A hydroxyl or carboxyl at the C« of the synthesized substance will appear, according to the nature of the polar group at Cn of the steroid. The respective characters and positions of C2i and Ci2 will permit the appearance of a cycle formed by five carbons and an oxygen, characteristic for the pyranic form of newly synthesized substances. An interesting confirmation of the template hypothesis was obtained when glucosamine which, according to the hypothesis, is synthesized by the cortisone molecule, was found to induce in patients many of the clinical changes which are obtained by treatment with cortisone. We will consider these results later in our discussion of therapy. The capital role played by glucosamine, galactosamine and the respective uronic acids in the con¬ stitution of the connective tissue represents the “missing link” for the explanation of the relationship between cortisone, the other neoglucogenic corticoids, and this tissue. Some part of the therapeutic effect obtained

Google

UNIVERSITY OF MICHIGAN

146

/

RESEARCH

IN

P H YS I OP ATH OLOGY

with these neoglucogenic corticoids in diseases of the connective tissue has to be attributed to the intervention of the amino sugars. In the study of anti-fatty acid activity, glycerol and glycerophosphoric ion were found to control the absorption and circulation of saturated mono-, di-, or tri-unsaturated free fatty acids. The sterols appear to counterbalance the normal polyunsaturated members while adrenal corticoids, and espe¬ cially the neoglucogenic corticoids, counteract the toxicity of fatty acids in general and of the abnormal conjugated members in particular. Research done in our laboratories by E. F. Taskier indicates that the adrenals in¬ tervene in the defense mechanism against fatty acids, and especially against the conjugated members which appear to be related to abnormal condi¬ tions. (Note 17) The part of our research concerned with the role of lipoids in normal and abnormal physiology has been almost entirely guided by the concept of an antagonism between the two groups, one with a positive and the other with a negative polar character. This specific aspect has led us to study, together with the fatty acids and the anti-fatty acids, other sub¬ stances related to this antagonism. In the group of lipoacids or acidic lip¬ oids, as obtained from tissues, organs or organisms, we recognized the group of porphyrinic acids, related to various hemes present in the organ¬ isms. In the group of anti-fatty acids obtained from the same sources, different constituents form the insaponifiable fractions. As related to this dualistic aspect we have studied another group of substances, which appear to act in the organism against the anti-fatty acids themselves. These other substances would represent a kind of biological brake to counteract an exaggerated intervention of anti-fatty acid con¬ stituents. We have made a special investigation of two substances of this group, glucuronic and sulfuric acid anions, which characteristically seem to op¬ pose certain anti-fatty acid substances. These substances appear as a result of an exaggerated oxidation of normal metabolites. Under abnormal condi¬ tions, the oxygen resulting from the intervention of peroxide may be fixed to carbohydrates even before they have undergone the preliminary fer¬ mentative transformations seen in normal metabolism. With the aldehyde group bound to phosphoric acid, the oxidation takes place at C«, the second most reactive carbon in the molecule. This direct oxidation would repre¬ sent, according to our view, one of the sources of glucuronic acid. Simi¬ larly the sulfuric anion would result from the oxidation of sulfur present in the organism. They correspond to the oxygen phase of offbalance D.

Digits

Google

UNIVERSITY OF MICHIGAN

LIPIDS

AND

LIPOIDS

/

147

Glucuronic and Sulfuric Anions Urine specimens that contain abnormal oxidizing substances show sig¬ nificant amounts of glucuronic and sulfuric acid compounds. (Note 18) The analysis of the conditions under which these two substances exert anti-toxic activity permits a better understanding of their role in general biology. A certain parallelism exists, and has always been emphasized, between a detoxifying and an eliminating function exerted by these two radicals. Not only do sulfo- and glucurono-derivatives appear in the urine, but it often has been noted that glucuronic acid intervenes when large amounts of certain substances, such as menthol and phenol, are present and there are insufficient sulfuric acid radicals to insure detoxification and elimination. When mineral sulfates are administered, the proportion of sulfo-derivatives increases. This parellelism appears especially interesting when we recognize that sulfuric acid represents the end result of the oxidation of sulfur introduced into the organism in combinations in which it is a bivalent negative ele¬ ment. Only a smaller amount of sulfur is introduced as a hexavalent posi¬ tive element: that is, as sulfate. Sulfur is introduced mostly in bivalent negative form, as in methionine, cystine, etc. Both sulfuric and glucuronic acid result from oxidative processes, acting in one case upon the thiol group and in the other upon glucose. The relationship between sulfuric and glucuronic acid goes still further. It has been noted that glucuronic acid appears when enough sulfuric radi¬ cals necessary for detoxifying action are not available. However, this is not entirely true since one process does not duplicate the other. Qualitative differences intervene. (Note 19) The significance of glucuronic acid in the defense mechanism seems clearer when we recognize that, with but few exceptions such as benzoic acid, all the substances with which glucuronic acid combines are lipids or lipoids having one or more positive polar groups. The combination with glucuronic acid takes place through these positive polar groups. (Note 20) In our view, glucuronic acid like sulfuric acid, has a specific role in the defense of the organism and this seems to be directed especially against lipids or lipoids with a positive polar group. Bound by glucuronic acids, the latter are eliminated as excremental substances. Glucuronic acid thus would act against many anti-fatty acid agents. We can conceive of sulfuric and glucuronic acids as means by which organisms are protected against an exaggerated activity of anti-fatty acid agents. Along the same lines, when lipoids with positive polar groups are predominant and able to act

Digitized by

Google

UNIVERSITY OF MICHIGAN

148

/

RESEARCH

IN

PH YSIOP ATHOLOOY

in an exaggerated manner to oppose the fatty acids physically and chemi¬ cally, the same means can be utilized to reduce this exaggeration. Thus, the intervention of glucuronic acid as a result of an abnormal oxidation of glucose induced by fatty acids appears to be biologically sound. This is also true for the sulfuric radical. The importance of these substances does not reside only in the fact that the organism can easily produce them in larger quantities than fatty acids. The fact that they combine to form excremental substances is important too, for in this way, they help in materially eliminating the anti-fatty acid substances from the organism. This would not take place if only a com¬ bination with fatty acids were possible, since the esters of fatty acids are usually retained in the organism and, under certain circumstances, can again liberate their constituents. The intervention of glucuronic acid and sulfuric acid appears to be more effective than that of the fatty acids which have their own activity and are more toxic in exaggerated amounts. This appears to be especially true in the case of glucuronic acid because the amount of glucose available is practically unlimited as compared with other metabolites. Glucuronic and sulfuric acid would thus intervene in the biological antagonism between fatty acids and anti-fatty acid sub¬ stances, inactivating and eliminating agents from the last group, especially when in excess. Teleologically speaking, their intervention appears to be still more interesting since the body has, as part of its defense mechanism, a tendency to manufacture anti-fatty acids in excess. The intervention of agents other than fatty acids would prevent a vicious circle and permit an excess of anti-fatty acids to be removed by excretion.

FATTY ACIDS VS ANTI-FATTY ACIDS This study of the relationship between fatty acids and anti-fatty acids has been guided by the dualistic concept. It must be recognized, however, that the direct activity of these substances could be largely reduced to that of one group, the fatty acids. The action of anti-fatty acids is largely indirect. They control and thus limit the activity of the fatty acids. It is within this framework that the different anti-fatty acids selectively influence different specific functions of the free fatty acids. The lipids and associated constituents with their multiple activities create for each entity a balance responsible for many of the manifestations of the entity. Variations in manifestations can be attributed in large part to qualitative and quantitative variations in the intervening lipids. A sys-

Digitized by

Google

UNIVERSITY OF MICHIGAN

LIPIDS

AND

LIPOIDS

/

149

tematization of these variations would help us understand many of the processes encountered in normal and abnormal physiology. As we have mentioned before, the balance between two antagonistic forces, especially for normal conditions, is not static. Instead, there is alternating predominance of the forces, which results in an oscillatory movement. Several groups of such coupled forces, each group with its proper rhythm, are at work. Operating simultaneously, they make for a series of very complicated variations. Yet analysis is possible since each of the variations follows a dualistic pattern. The variations, as they occur at different levels and with different intensities, have been identified through various tests. In a second step they have been tentatively corre¬ lated with changes in lipids. And next, didactically, lipid changes have been related to various etiologic factors, some intrinsic and some extrinsic. Sex The influence exerted by the sex of the organism upon lipidic balance was brought to our attention by a curious effect seen when cholesterol was administered in an ether-oil solution to rats. Only the females showed paraplegia and ulcerations of the hind legs. While castration or administra¬ tion of sex hormones did not alter this response, it was influenced by the administration of two groups of lipids. The insaponifiable fraction of hu¬ man placenta, for instance, was seen to induce a high sensitivity to this preparation of cholesterol even for males, while the acid lipidic fraction of placenta prevented paraplegia in females. (Note 21) Similarly, the fact that in females alone, adipous cells appeared quickly in the skin of the ear after the application of sulfur mustard could be related to the intervention of the insaponifiable fractions. (Note 22) Starting with these observations, it could be seen that, in general, a higher proportion of positive lipids exists in females than in males. This could be shown by direct analyses and by analyses of manifestations re¬ lated to such lipids. While many differences are to be seen in various manifestations between females and males, only some could be related to the direct or indirect intervention of sex hormones. In such instances, castration with or without the administration of sex hormones was able to change, and even to reverse, the differences in manifestations seen between sexes. However, in instances in which these measures were without effect, the differences could be related to the intervention of lipids.

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

150

/

RESEARCH

IN

P H Y S I OP ATH OLOOY

Age The changes in lipidic balance related to age have been made the object of an extensive study which also sought to determine the role of lipids in aging processes. A general predominance of positive lipids, more manifest in the cellular and tissue levels than in the blood, was seen in youth. This would be expected in view of the special metabolic influence exerted by this group of lipids. The anoxybiotic character of metabolism induced by sterols results in the intervention of dehydrogenases which lead to an abun¬ dance of hydrogen ions. This, in turn, leads to a predominance of the kind of syntheses which favor anabolism. Growth thus could be related to the predominance of lipids with positive polar groups, especially sterols. Aging processes, on the contrary, could be related to a predominance of lipids with negative polar groups, especially fatty acids. This predomi¬ nance could be found especially at the cellular level, as seen in cultures of tetrahymena. (Note 23) In complex organisms or in rats (Note 24) in which an increase in the proportion of fatty acids at the cellular level is present, an opposite change occurs at the systemic and even at the organic level. There is an excess of cholesterol, this time limited to the higher levels, as revealed through analyses of the blood, for instance. Changes in the blood vessels are related in part to this excess of sterols at the systemic level. Many manifestations have confirmed such an offbalance with sterol pre¬ dominance at higher levels. For example, we found the urine surface tension abnormally high in old age. (Note 25) Similarly, skin wheal absorption in old people requires more than 90 minutes for completion as against approximately 20 minutes in middle-aged adults. A predominance of fatty acids at lower levels and of sterols at higher levels would thus characterize the changes in lipidic balance related to old age. (Fig. 68) Other Physiological Factors The study of the role of lipids in various physiological functions was made indirectly for the most part, using the tests previously mentioned which were interpreted in terms of duaiistic patterns. These were related to the general offbalances A and D and, through them, attributed ultimately to a predominance of sterols or fatty acids. Sleep in itself, without relation to night or day, was found to induce a marked change, comparable to a type A offbalance with predominance of sterols. Subjects with pain of an acid pattern often correlate the ap¬ pearance of pain with sleep, the pain occurring uniformly at the moment they wake up. In these cases, the urine shows a low specific gravity with

Google

UNIVERSITY OF MICHIGAN

LIPIDS

AND

LIPOIDS

/

151

a high pH and a high surface tension, corresponding to an A type offbalance. As we will see, in subjects with an intensive A type offbalance, nocturnal polyuria and pollakiuria occur. Sexual intercourse in males was seen to induce, in analyses, transitory changes similar to an offbalance of type D, corresponding to a predomi¬ nance of fatty acids. In females the change corresponds to a transitory offbalance of type A, manifested by changes at the systemic level. Muscular exercise was seen to induce, in a first phase during the exercise itself, 100

60

0 K) 20 30 40 50 60

minutes Subjects between 15 and 35 years

0

102050405060 70 80

minutes Subjects between 65 and 87 years

Fig. 68. The disappearance time for the wheal induced by the intradermic injection of 0.2 cc saline, varies with the age. In old age, the wheal often persists for more than 90 minutes.

changes comparable to an offbalance type D. This phase is followed by a much longer phase of type A, indicating sterol predominance. Intensive mental exercise produces a marked change similar to offbalance A, with all urinary tests showing the patterns found with predominance of sterols. The responses attributed to influences exerted by external factors could be integrated in the same dualistic mechanism. All the data indicate the manifest influence exerted by the time of day. Two marked changes are seen, one around four o’clock in the morning and the other usually around eight or nine o’clock in the evening. The morning change corresponds to a predominance of sterols, the evening to predominance of fatty acids. These changes together with the clinical manifestations related to time of day

Digitized by

Goo

Original from UNIVERSITY OF MICHIGAN

152

/

RESEARCH

IN

P H Y S I O P A TH OL O G Y

appear in a new light when interpreted not as being the direct results of time changes but rather of patterns of diurnal activity and nocturnal rest. This explains why in rats and mice, which are nocturnal animals, most of the analyses show variations related to the time of day opposite to those in humans. Other variations could be recognized more strongly related to time of day. Variations with a 24-hour rhythm could be seen, for instance, for urinary surface tension in mice. But, when rats and mice were main¬ tained for a length of time under artificial conditions, with light during the night and dark during the day, the animals changed their habits, becoming active during the day and sleeping during the night. After a certain time, most of their analytical patterns such as urinary pH, blood leucocytes, eosinophiles etc. changed, acquiring the type of variation seen in humans. Urinary surface tension remained unchanged for a long time. (Note 8 Chapter IV) Even more interesting were other changes which could be re¬ lated to changes in external temperature. The urinary surface tension measured in rats in the morning for long periods of time showed varia¬ tions related to changes in the temperature of the environment. (Note 26) (Fig. 69) The importance of temperature led to its more detailed investigation. Variations in lipidic balance have been found to parallel variations in body temperature. The blood of normal individuals is richer in sterols than the blood of those with hypothermia. Furthermore, in moments of high tem¬ perature, more sterols are found than in moments of low or normal tem¬ peratures. An increase of fatty acids occurs in conditions with hypothermia. These changes were confirmed also by the correlation between blood con¬ tent in lipids and temperature in different abnormal conditions. In shock with hypothermia the blood is rich in fatty acids, while in infections with fever, it is rich in sterols. The role of temperature was also investigated by studying the influence upon the lipidic balance by externally applied heat or cold. Characteristic variations could be seen in human analyses under the influence of hot and cold days, and of local applications of heat and cold. Manifestations corre¬ sponding to predominance of lipids with positive character were induced by heat, while others corresponding to predominance of lipids with nega¬ tive character were induced by cold. Variations were seen in animals kept in an incubator or in a refrigerator. (Note 27) We will see below, by study¬ ing their influence at different levels, the importance of these variations produced by temperature. The influence exerted by barometric changes could be seen in changes in total blood potassium, the two curves being parallel. Similar changes

i by

I UlUCCU

Google

UNIVERSITY OF MICHIGAN

LIPIDS

AND

LIPOIDS

/

153

could be observed related to the atmospheric humidity. Other tests as well, such as urinary pH, calcium excretion, etc., show a similar relationship but to a much lesser degree. (Note 28) The influence exerted by the environ¬ ment could explain the changes seen from one day to the other in various analyses. (Note 28)

Fig. 69. The curves of the average values of surface tension of two groups of 20 male rats each, and two groups of female rats each, show parallel changes with the inverse curve of the temperature of the environment.

The influence exerted by changes in seasons was studied. An increase in fatty acids in winter and of sterols in summer could be noted. These increases also could be largely related to the seasonal variations in tem¬ perature. Very hot days were marked by analyses indicating intervention of lipids with a positive character. The influence exerted by the seasons was seen even in the responses of organisms to pathological conditions such as

Digitized by

Google

Original from UNIVERSITY OF MICHIGAN

154

/

RESEARCH

IN

PHYSIOPATHOLOOY

tumors; variations in character and growth of experimental cancer could be noted. (Note 29) The relationship of many viral infectious diseases to seasonal changes which has been noted in many epidemiological studies could be related to the changes in lipids. (Note 30) Effect of Antagonistic Lipids at Different Levels A more complete study of lipids under the dualistic concept was made by considering their activity at different levels of hierarchic organization. This research was greatly facilitated by the degree of individuality which different biological levels exhibit when they are part of the hierarchic or¬ ganization of complex organisms. It was also aided by the availability of lower organisms in nature which correspond to various hierarchic levels. Through this double approach, the information obtained showed the im¬ portance of the relationship between the levels of the complex organism and the influence exerted by lipoids. If high doses of the agents are ap¬ plied, the influence is exerted upon all the levels. A preferential influence is exerted upon a single level if reduced doses are used. When medium size doses are administered, to the preferential effect upon one level a reactional response at other levels is added. This results often in concomitant opposite effect at these levels. Effects of Lipoids on Viruses The antagonistic effects of positive and negative lipids were evident in the study of their action upon viruses. Generally, agents with a positive polar group appeared to create favorable conditions for the development of viruses, while those with a negative polar group had an opposite effect. This influence, which was first seen in phages in vitro, became still more evident in viral infections. Subcutaneous administration of positive lipids, such as sterols or insaponifiable fractions of organs, induced greater local receptivity to viruses. In experiments with smallpox virus in rabbits, for instance, virus inocula¬ tion of the skin induced an exaggerated response in those areas where positive lipids previously had been injected subcutaneously compared with the response in other previously untreated areas. In less sensitive species such as mice and rats, positive lipid injections induced abnormally high local receptivity to virus inoculation. Intracerebral injection of sterols followed by subcutaneous inoculation with smallpox virus invariably pro¬ duced nervous system localization of the virus. Intraperitoneal adminis¬ tration of sterols in very high doses in mice prior to smallpox inoculation produced a great degree of central nervous system localization. Intra-

Digitizec

i by Google

UNIVERSITY OF MICHIGAN

LIPIDS

AND

LIPOIDS

/

155

cerebral virus inoculation, after subcutaneous administration of high doses of anti-fatty acids, brought death earlier in test animals than in controls given intracerebral virus alone. A striking opposite effect was noted for lipids with a negative polar character. In rabbits, subcutaneous injection of a polyunsaturated fatty acid set up a local skin area refractory to smallpox virus inoculation, al¬ though inoculation was positive in other areas of the body. Death also occurred later, following intracerebral inoculation with a neurotropic virus in test animals given subcutaneous or intraperitoneal injections of fatty acids, than in controls. This partially protective effect was opposite to the increased receptivity seen in animals injected subcutaneously or intraperitoneally with insaponifiable fractions and intracerebrally with the same virus, where death appeared earlier than in controls. The antagonistic effects of the two groups of lipids for viral infection appeared interesting from several points of view. The effects were local, at the cellular level, where viruses themselves act. Subcutaneous injection of lipids induced manifest changes in response toward the virus in the skin at the site of injection, and little or no change at all elsewhere. We have utilized this fact, as we will see below, to obtain information regarding the level at which various agents act. A change induced in receptivity to viruses, limited to the skin at the site of injection, would indicate activity of the agent at the cellular level. Tests based upon the skin response to smallpox virus infection have shown that, among the lipids with a negative polar character, a maximum of influence is exerted by the insaponifiable fraction of organs of exodermic origin from species sensitive to the virus. The insaponifiable fractions of rabbit skin and rabbit brain were the most active of the lipids tested. Among the fatty acids, the preventive effect was seen to increase with the degree of desaturation. It was almost entirely absent in saturated fatty acids, notably present in polyunsaturated fatty acids. The increase and decrease in receptivity of the skin to smallpox virus following injection of lipids also furnished information about the roles of the polar and nonpolar parts of lipids in this specific activity. An opposite effect was seen between two groups of substances having the same non¬ polar group but differing in their polar groups. While the polyunsaturated fatty acids of safflower oil, for instance, greatly reduced receptivity, the same polyunsaturated members having alcohols as polar groups increased receptivity. The polar group—negative or positive—appears to be the factor inducing the opposite effect. The role of the nonpolar group was studied by comparing saturated

i zed by

Google

UNIVERSITY OF MICHIGAN

156

/

RESEARCH

IN

P H Y S I O P A THOL OOY

and unsaturated acids and alcohols. Almost no activity was seen for the saturated. The unsaturated members were active in general, with activity in any direction increasing with the degree of desaturation of the nonpolar group. Thus, it appears that the nonpolar group determines whether a substance is active or inactive, but the nature of the activity—that is, in¬ creasing or decreasing receptivity—is determined by the polar group. The influence exerted by agents with a positive character upon viral infection would explain the seasonal changes in clinical manifestations which are especially interesting for the paralytic form of poliomyelitis. We could show experimentally that when mice, after being inoculated subcutaneously with smallpox vaccine virus, are kept in an incubator at 37°C, all develop cerebral involvement, while such involvement appears in only a small proportion of other animals kept at room temperature, and does not appear at all in those kept in a cool place. As we could also show that one of the effects of exposure of an animal to a higher temperature is an increase in the body of the amount of free lipids with positive char¬ acter, this could explain the increase in the virus sensitivity of cells in the central nervous system which are especially sensitive to these lipids. This relationship would also explain the increased incidence of paralytic polio cases during hot weather. The presence of greater amount of lipids with positive character in youth helps also to explain the frequency and intensity of viral infections in children. (Note 31) The study of the effects of temperature and lipids upon viruses has shown that those effects are not limited to the host but also are exerted upon the viruses. (Note 32) The influence of heat and cold upon virus activity was studied in bacteriophages, where effects for virus and host could be separated. The direct influence upon the virus appeared relatively small and secondary to the changes which appear in the host itself. Bacteri¬ ophage, separated from microbes by filtration and kept in an incubator at temperatures 2-3 degrees C higher or lower than controls, showed no change in virulence. This was true as long as microbes were not present. Microbes kept at higher temperature were more sensitive to phages; when kept at lower temperature, they were less sensitive. This influence went so far as to change a sensitive strain to a refractory one, and vice-versa. The fact that microbes grown at higher temperatures favor the develop¬ ment of bacteriophage while those grown at lower temperature hinder it could be correlated with the change in the richness of lipids in the microbes themselves. Similar results were obtained when microbes were grown for a time in media containing fatty acids or insaponifiable fractions and were

Google

UNIVERSITY OF MICHIGAN

LIPIDS

AND

LIPOIDS

/

157

then removed and exposed to phages. These experiments (Note 33) indi¬ cate the direct role played by the lipids of the hosts in the activity of phages, and would explain the influence exerted by temperature. Through the change in the lipids of the host, the virus changes too, becoming more active if grown in microbes at a higher temperature and less aggressive if passed through microbes kept at lower temperature. Effects of Lipids on Microbes The antagonistic effects of the two groups of lipids upon microbes were investigated. As an example, we will mention here the characteristic changes in Bac. anthracis treated with polyunsaturated fatty acids and insaponifiable fraction preparations. (Fig. 70) We investigated the microbes for their morphological, tinctorial, cultural and virulence characteristics. With the fatty acids added to media, changes which can be considered to be mutational were induced, leading to tiny Gram negative microbes grow¬ ing on agar as transparent small colonies. The changes, however, were reversible. Usually several passages in normal media were sufficient to produce reversal. First small and separate, then larger and more confluent Gram positive granules were seen to appear in the microbes which, them¬ selves, also became progressively plumper. Ultimately, all the character¬ istics,—morphological, tinctorial and cultural—of the normal microbes reappeared. (Fig. 71) Microbes showed opposite changes when treated with insaponifiable fractions, (Fig. 70) losing their bacillus form. Abnormally intensive Gram

Fig. 70. Influence of lipids upon microbes. Schematic drawing of the changes in¬ duced in Bacillus Anthracis by the influence exerted by the two groups of lipids. Treated with sterols (a) as in the unsaponifiable fraction of placenta, the microbes change into cocci irregularly shaped and intensely retaining the gram stain. Treated with fatty acids (c) from cod liver oil, the bacilli change into very tiny gram nega¬ tive microbes, (b) shows untreated microbes.

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

158

/

RESEARCH

IN

PH Y S IO P A TH OLO G Y

Fio. 71. Lipids and microbes. Drawing of the progressive passage toward normal bacilli of the tiny gram negative microbes obtained through the treatment of Bac. Anthracis with fatty acids. The passage takes place usually in successive steps. The gram positive formations appear first as fine granules; they later become clumps and finally give the microbes their normal aspect.

positive cocci appeared. They grew on agar as very thick creamy white colonies. These changes were seen to persist for a long time and seldom were spontaneously reversed. Treatment with fatty acids induced reversal although inconsistently. We attempted to correlate the differences in changes induced by different lipids to the different levels of the microbe at which they work. The change to cocci can be regarded as corresponding to an influence exerted upon the membrane and the change to Gram posi¬ tive to an influence upon differentiated formations present in the body. (313) Effects of Lipids on Protozoa The effects of lipids upon monocellular organisms, especially tetrahymena pyriformis, were studied and an effort made to relate the nature of the main changes induced in these protozoa to changes observed at the cellular level of complex organisms. An initial effect was noted on the polarity in protozoa which seemed to be oppositely influenced by long chain polyunsaturated fatty acids and sterols. Lipids with a positive char¬ acter were seen to induce a change in the form of protozoa causing them to become almost round, a change considered to correspond to reduced polarity. Lipids with a negative character had an opposite effect; the tetrahymena became abnormally elongated. The administration of higher amounts of polyunsaturated fatty acids was seen to induce immediate changes localized at the anterior pole of the organism, changes which ultimately lead to the breakdown of the mem¬ brane particularly at this point. This effect parallels in intensity the degree of desaturation of the fatty acids. Other changes were seen in growth rate and survival time and, thus, in the aging process. (Note 34) (Fig. 74) At the same time, resistance to heat was seen to increase as the result of treatment with negative lipids, while it decreased after treatment with

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

LIPIDS

Control

AND

LIPOIDS

/

159

Treated with fatty acids

Fig. 74. In a direct action of fatty acids on tetrahymena, a passage of fluid occurs at the surface with a break of the membrane especially manifest at the untcrior pole (a), control untreated (b), (1200x).

the positive sterols. (Note 35) The same influence upon the aging processes, as manifested in a prolongation of the life-span, was noted for polyunsatu¬ rated fatty acids with a long chain and even for some members of the saturated scries but with a shorter chain. Effects of Lipids on Complex Organisms Morphological Changes—The same level separation was used in the study of the effects of lipids on complex organisms. Acting at chromosomal levels, lipids led to the appearance of monstrosities. Various lipids, espe¬ cially insaponifiable fractions of organs, were injected into larvae of flics. While an immediate change in the cells of the larvae could be traced to the subnuclear level as seen in chromosomes, monstrosities were seen to be induced in the resulting flies. A similar effect became evident when lipids were injected into hens' eggs before or during incubation. Especially with cholesterol but also with insaponifiable fractions of organs, a high proportion of chickens were hatched with spastic paraplegia. The same problem is being studied, in collaboration with P. Fluss, in Drosophila melanogaster, grown for many generations in media to which an entire series of different lipids from one or the other group are added. This study is in progress and the results will be published later. We have seen that the antagonistic effects induced by the two groups of lipids could be related ultimately to opposite changes in the fundamental biological process of aging. This appeared clear for lower morphological levels of organization and was especially evident for cells. While anti-fatty

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

160

/

RESEARCH

IN

PHYSIOPATHOLOCY

acids induce changes which can be regarded as corresponding to prolonged youth, the polyunsaturated fatty acids induce rapid aging with pyknosis and karyorrhexis and death of the cells as old entities. This could be seen clearly in tumors, in which cells with youthful character lead to non-necrotic tumoral masses, while cells that age rapidly produce necrosis in the tumors followed by ulceration if the tumor is superficial. The effect of conjugated fatty acids was somewhat more complex, in¬ dicating an abnormality in the induced processes. Their administration was followed by the appearance of cytoplasmic and even nuclear vacuoles, corresponding ultimately to an anomaly of water metabolism. The effect of lipids upon adipous cells appeared to be of special inter¬ est. The anti-fatty acids, especially the sterols, when injected subcutane¬ ously in animals, induced a characteristic process in the adipous cells near the injection site. These cells became very enlarged and highly irregular, with their content changed into an emulsion only slightly stained with Sudan. The fatty acids, on the contrary, imparted to adipous cells an ab¬ normal resistance to destruction. They remained persistently unchanged even in the midst of very active processes which usually cause them to disappear. Unchanged adipous cells were found encircled by the invading cancerous cells, deep within tumors in animals treated with fatty acids. On Pain—From the start of this research, the opposing effects of the two groups of lipids upon pain has been most impressive. For the fatty acids the degree of saturation is important. The saturated members of the fatty acid series and even oleic acid are entirely without effect. Linoleic and linolenic acids show a slight influence, while the polyunsaturated mem¬ bers show a marked effect. Administration of highly unsaturated fatty acids and of acid lipidic fractions of certain organs, such as placenta, liver, spleen or blood, uniformly decreased pain of an acid pattern and increased pain of an alkaline pattern. These opposite effects have, from the beginning of our study, contradicted the idea that this influence upon pain was the result of the direct action of these agents upon the nervous system. Further¬ more, the opposite effects exerted upon the same pain by the other group of lipids have confirmed the hypothesis that the action takes place at the level of the painful lesion, where the differences between the two pains was found to correspond to two opposite acid-base offbalances. In the study of the effects of lipids on the pH of the second day wound crust, made in collaboration with Carlos Huesca, we have demonstrated that lipids influence pain through changes induced on the acid-base balance present at the tissue level. The positive lipids constantly lowered this pH while the negative lipids elevated it. (Note 1 Chapter V) Even more im-

Google

UNIVERSITY OF MICHIGAN

LIPIDS

AND

LIPOIDS

/

161

portant than this temporary pH effect in establishing the mechanism of lipid action in pain was the change in the actual pattern of an existing pain after administration of these agents. Polyunsaturated fatty acids in sufficient amount were found to convert an acid-pain pattern to an alka¬ line pattern, while sterols changed an alkaline pattern into an acid one. We will return to this important fact later. A pathogenic role for lipids becomes evident too, when pain can be induced through the administration of lipids in previously painless lesions. Such lesions treated with large amounts of lipidic preparations became painful. An alkaline pattern of pain was seen to appear after fatty acid administration, while an acid pattern followed use of the insaponifiable fraction. (Note 36) At the tissue level, lipids also affect such acid-base symptoms as vertigo, itching, dyspnea, tremor, and even mental diseases. In these conditions the same antagonism between the two groups of lipids—and the same opposite effects upon the acid and the alkaline pattern—can be noted along with the same possibility for changing the pattern to the opposite type if big doses of lipids are administered. Wound Healing—The same manifest antagonism between the two groups of lipids was also noted in their influence upon the evolution of wounds. Changes in the sloughing and healing process were followed by measuring the size of wounds (Note 37) as well as by serial histological examinations. The lipids with a negative polar group were seen to retard the evolution of the processes by prolonging the first catabolic phase. Posi¬ tive lipids generally had an opposite effect. However, here too it could be observed that sterols have relatively little effect on the healing of connective tissue, but manifestly favor proliferation of the epithelia. This was espe¬ cially evident in the changes in scar formation of the skin of treated ani¬ mals. In rabbits treated with cholesterol, the epithelial scars were found to have 8-10 layers instead of the 2-3 characteristic for the rest of the skin and for the scars in control animals. Regeneration—In collaboration with E. F. Taskier we studied the effect of lipids upon the regeneration of liver in rats, after the resection of almost 3A of this organ. The rate of regeneration could be estimated by correlating it to the time of appearance of fatty droplets filling up almost all the cells, as a first step in the regenerative process. In very young ani¬ mals, this change in fatty liver cells was seen to take place even within the first 24 hours after resection. The change was progressively delayed as the age of operated animals increased. In old animals the change in fatty liver cells appeared only after the fourth day.

Google

UNIVERSITY OF MICHIGAN

162

/

RESEARCH

IN

P H Y S I O P A T H OLOOY

The administration of lipids had a marked effect on appearance time of fatty cells. Sterols induced precocious appearance in old animals. From this point of view, sterol-treated animals appeared to react as young in¬ dividuals, with fatty cells evident even on the second day. The fatty acids and acid-lipidic fractions of organs showed an opposite effect, delaying the time of appearance of the fatty cells. Young animals treated with polyun¬ saturated or conjugated fatty acids showed no fatty droplets in the liver cells for as long as three to four days. With higher doses of the same agents, the fatty infiltration did not occur at all. It is interesting to note a parallelism between fatty infiltration of liver cells and the richness of adrenals in Sudan op hil substances. An almost complete lipid depletion of the adrenals was seen after high doses of fatty acids and coincided with a total lack of fatty cells in liver regeneration. (Note 38) Organic Level—Effects of the two antagonistic groups of lipids at the organic level have been studied in terms of manifestations clearly associ¬ ated with various organs. We will review these effects briefly here, with more details to come when the therapeutic use of lipoids is discussed. Intestines—The influence of lipids upon intestinal function is marked by the same antagonism between the two groups of agents. Oral adminis¬ tration of large amounts of fatty acids, especially higher unsaturated such as obtained from cod liver oil, was usually followed by diarrhea. Diarrhea also occurred after parenteral administration of these substances in large amounts. It was interesting to note that parenteral administration of the acid lipidic fraction of placenta, blood or even organs had a marked in¬ fluence upon the colon and rectum in particular. High doses produced tenesmus with a mucous or even sanguinolent secretion. This localization of the effects of the lipidic fraction appeared to be especially interesting from a therapeutic point of view, as will be seen later. The oral or par¬ enteral administration of the opposite group of lipids, sterols and insaponifiable fractions, has an opposite effect, a constipating one, which we will discuss later together with its therapeutic aspects. Kidney—The manifest opposite effects exerted by the two groups of antagonistic lipids upon diuresis raise the question of where these effects take place. While a systemic effect can be recognized, a more direct inter¬ vention upon the kidney also must be considered. The addition of the acid lipidic fraction of organs, and especially those obtained from pork kidney, to the perfusion fluid in a dog kidney preparation produces a manifest decrease of excreted urine. The administration of insaponifiable fraction

tized by

Google

UNIVERSITY OF MICHIGAN

LIPIDS

AND

LIPOIDS

/

163

has a marked diuretic effect which we will discuss below with its thera¬ peutic aspect. Nervous System—Interesting effects by the two groups of antagonistic lipids upon many manifestations of the central nervous system have been noted. Convulsions—Administration of sterols and insaponifiable fractions of many organs such as placenta, liver, butter, eggs, etc., in large amounts induces convulsions in rats. Convulsions also were noted in humans when huge doses of these agents were administered. But even in relatively small amounts, these lipid agents sensitized animals to the administration of other convulsant agents. In rats or mice receiving such lipids, thiamine chloride induced convulsions in doses without effect in controls. (Note 39) An opposite effect was observed for lipids with negative character. Saturated fatty acids showed no influence on thiamine-induced convulsions. Such convulsions were prevented by the administration of nonsaturated members. The effect was related to the degree of desaturation of the fatty acids. With increases of the iodine number, the necessary effective doses of these fatty acids became progressively smaller. While hundreds of milli¬ grams of mono- and diethenic acids were necessary for each 100 gram of body weight, the anti-convulsant effect was obtained with only a few milli¬ grams of clupanodonic acids, and with still less of the nonenic acid, bixine. The study of the pathogenesis of convulsions also covered the influence exerted by these lipids of the adrenal corticoids. The administration of mineralocorticoids, especially desoxycorticosterol, even in small doses, to subjects who had received any one of the lipids with a positive polar group, such as cholesterol or insaponifiable fraction of placenta, liver or kidney, was followed almost invariably by convulsions. We will present more de¬ tails on this effect later in the discussion of synthetic substances. For the moment we want only to note the relationship between mineralocorticoids and lipids with positive character in the pathogenesis of convulsions. The concomitant intervention of the two factors—an offbalance induced by lipids with positive character, and action of mineralcorticoids—seems to provide new light on the pathogenic problem of epilepsy and convulsions in general. Coma—The role of cortical hormones in the pathogenesis of convul¬ sions was confirmed by the opposite effect produced by neoglucogenic corticoids. We will see later that the administration of cortisone to subjects receiving higher alcohols such as heptanol, octanol or octandiol in large doses, induced a subcomatose condition at first which progressively changed into coma. (Note 40) Opposite properties of the mineral and neoglucogenic

Google

UNIVERSITY OF MICHIGAN

164

/

RESEARCH

IN

P H Y S I O P A T H O L OG Y

corticoids, which made Seyle separate them according to their “phlogistic" and “antiphlogistic" activity, would explain the two opposite manifesta¬ tions inducing convulsions and coma, produced in individuals previously treated with the same anti-fatty acid agents. On Cardiac Rhythm—The influence exerted by the two groups of lip¬ oids upon the cardiac rhythm was studied under the same dualistic aspect. The effects observed can easily be interpreted considering the role of the differentiation of the cardiac cells for their part in the cardiac physiology. The role of a cell in cardiac physiology is a direct function of its own automatism which can ultimately be related to its degree of differentiation. The fact that the two groups of lipids act antagonistically upon this cellu¬ lar differentiation, the acid lipids exaggerating it and the insaponifiable fraction of sterols reducing it, has explained some of the effects induced by these agents upon normal and abnormal cardiac rhythm. (Note 41) On Oestral Cycles—The action of the two groups of lipids at the or¬ ganic level was also studied in the rat ovarian cycle. Daily, and even twice a day, vaginal smears were made in animals treated with these agents. When large amounts were administered, both groups suppressed the cycle. With smaller doses, only the lipids with positive polar groups, especially sterols, produced this effect. Systemic Level—Blood has appeared especially suitable for in vitro and in vivo studies of the effects of the two groups of lipids at the systemic level. The effects on different blood constituents were analyzed and led to very conclusive results. We will outline here the principal points of this study. Under the influence of anti-fatty acids, the erythrocytes become more turgescent, increase in volume, show a strong refringency of their crown in dark field examination, and remain isolated from one another. The sedimentation rate, if previously high, is reduced by treating blood in vitro with insaponifiable fractions of organs. Oxygen appears to be retained longer in treated red cells than in controls. The fatty acids have an opposite effect. Under their influence, the red cells become crenelated and develop a tendency to form sludges. The sedi¬ mentation rate is increased. The color of the treated blood is dark and, even after oxidation, rapidly darkens again. In vivo, lipids with a positive character induce leucocytosis, those with a negative character leucopenia. This last effect is seen even in vitro. In Note 42, the influence exerted by lipids upon the blood is presented with more details. (36) On Temperature—The administration of sufficient amounts of positive lipids induces a frank elevation of temperature, while hypothermia follows

Digitized by

Google

original rrom

UNIVERSITY OF MICHIGAN

LIPIDS

AND

LIPOIDS

/

165

the administration of negative lipids. The relationship between temperature and lipids, however, is not so simple since changes in external temperature influence the balance between the antagonistic lipids. For example, animals kept in incubators at a temperature of 35°C show an increase in lipids with a positive character. Animals kept in a cool place, such as a refrigera¬ tor, show an increase in lipids with a negative polar group. The organisms are able to combat the increase of lipids with negative character by means of the normal defense mechanism, but are less capable of dealing with an increase of lipids of positive character. Therefore, while a high proportion of animals kept in refrigerators adapt themselves to the new conditions, those in incubators die in a few days. On Systemic Patterns—The influence exerted by lipids upon various other systemic manifestations which are reflected in abnormal patterns in urine analyses has been studied. In general, the fatty acids induce patterns corresponding to the oflbalance of type D, while the sterols induce patterns of the type A oflbalance. Here again we must emphasize that any lipid, if administered in large quantity, influences all analytical values. A certain specificity, however, is noted since, in relatively small doses, lipids induce changes only in certain values. Because of the inherent technical problems concerning the patterns, only a few analyses could be followed accurately over the period of time necessary for a clear recognition of changes in small laboratory animals. It is for this reason that most of our studies in this area were made on humans where pattern changes could be easily identified and followed over long periods. It is to be emphasized that, under these conditions, the influence of lipids is exerted especially upon already existing abnormal patterns, in¬ creasing or decreasing their deviations from the normal, or changing the patterns entirely. Abnormal patterns were induced through huge amounts of lipids, which very seldom were administered to patients. Table X shows schematically the analytical changes induced by the two groups of lipids upon various urine and blood analyses, expressed as patterns correspond¬ ing to abnormal conditions, as well as upon the manifestations present at other levels. We will discuss these effects in more detail when describing the pharmacodynamic properties of lipids and lipoids. Mechanism of the Lipidic Biological Activity The analysis of the changes induced by lipids has emphasized certain characters which appear of capital importance for the understanding of the biological intervention of these substances. In one kind of activity a lipid

Digitized by GCK >glc

UNIVERSITY OF MICHIGAN

166

/

RESEARCH

IN

P H Y S IO P A TH OL O G Y

acts through its lipoidic properties. From the data concerning its distribution in the organism it can be seen that, due to its solubility characters, a lipid introduced in an organism will be selectively retained by the existing lipidic system. When such intervention through its lipoidic properties takes place, the nonspecific character of the activity of the lipid is prevalent. A second kind of activity results from the bond realized through the charge of the polar groups. The positive or negative character of these polar groups deterTable

X

LEVEL

EFFECTS OF STEROLS

EFFECTS OF FATTY ACIDS

Cells

Prolongs youth character Increases potassium content Decreases sodium content Reduces membrane permeability Reduces cellular oxidation Reduces chloride content

Induces rapid aging Decreases potassium content Increases sodium content Increases membrane permeability Increases cellular oxidation Increases chloride content

Tissues

Lowers pH of lesions Lowers chloride content of lesions Lowers water content of lesions

Raises pH of lesions Raises chloride content of lesions Raises water content of lesions

Organs

Induces somnolence Induces diuresis Induces constipation Induces tachycardia

Induces insomnia Induces oliguria Induces diarrhea Induces bradycardia

Systemic

Induces hyperthermia Induces hypertension

Induces hypothermia Induces hypotension

Increases RC volume Decreases RC sed. rate Increases persistence of oxygen fixation Determines persistence of RC isolation Determines hyperleucocytosis Determines eosinophilia Decreases kalemia

Decreases RC volume Increases RC sed. rate Decreases persistence of oxygen fixation Determines formation of sludge Determines leucopenia Determines eosinopenia Increases kalemia

Induces water excretion Induces sulfhydryl retention Induces calcium excretion Induces chloride excretion Induces sodium excretion Induces phosphate retention Induces retention of surface active substances

Induces water retention Induces sulfhydryl excretion Induces calcium retention Induces chloride retention Induces sodium retention Induces phosphate excretion Induces excretion of surface active substances

Blood

Urine

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

LIPIDS

AND

LIPOIDS

/

167

mines thus the nature of this second kind of activity. A third kind of activity results from the chemical constitution of the polar group, which will induce selective combinations and consequently will have a more specific influence. A fourth group of changes are induced by the activity which takes place at the nonpolar group of the lipid and more specifically at the energetic for¬ mations present in it. They will have a still higher character of specificity. With this systematization of the activity of the lipids, a further sys¬ tematic analysis of the influence exerted by the lipids appears possible. Through its selective distribution, the administration of a substance having lipoidic properties will influence those entities which have lipids in an active form in their constitution. The influence exerted will thus be proportional to the richness of the entity in these active lipids. This fact explains why the administration of a lipid or lipoid affects selectively the abnormal entities rich in free lipids and to a much lesser degree, the normal ones. It is this selective distribution which will further limit the activity of the lipoid to the lipidic system and most manifestly to the abnormal entities. In the frame of this limitation, this activity results from the charge of the polar group. Similar effects are thus obtained for all the different lipoids which have the same electric positive or negative character of their polar group. This explains why one can use different agents from the same group and still obtain similar results. Agents chemically so different as fatty acids, mercaptans, persulfides, aldehydes or epichlorohydrine, have similar activ¬ ity because they all have negative polar groups. The characteristic of the effects resulting from the electrical character of the polar groups, is that they are common for the groups having the same sign and diametrically opposite for the agents with a positive or a negative polar group. This effect was clearly seen in fatty acids in which the negative car¬ boxylic polar group was changed into the positive primary alcohol. The biological effects of the new substance were opposite. It is in the third kind of activity that the chemical nature of the lipoids intervene. Certain effects resulting from the bond of an amino polar group will thus be different from that of the alcohols, although both act as positive energetic centers and as such have exerted other common effects. The same is true for the carboxyl and thiol groups. Still more specific appear the effects resulting from the intervention of the energetic factors present in the nonpolar group, such as the double bonds, and the energetic formations they realize such as conjugated, or two double bonds separated by a methylenic carbon. The various mechanisms involved have explained further the different kinds of biological effects which result. The action of the lipid by means of

ized by

Google

UNIVERSITY OF MICHIGAN

168

/

RESEARCH

IN

P H Y S I OP A TH OLOOY

the lipoidic effect will thus influence general, nonspecific manifestations, such as those concerning the permeability of membranes. Only secondarily, will these changes in membrane permeability influence the different meta¬ bolic processes which the membrane governs. In the second group of changes, related to the intervention of the polar groups, the antagonistic effects induced were seen to concern processes re¬ sulting from membrane permeability. It is only in a third change that a more specific action upon the different metabolic processes has to be con¬ sidered. These are concerned with an intervention upon metabolites or the agents governing them. The character of this last lipidic intervention is its specific influence exerted upon a definite metabolic system. We tried to interpret the influence exerted by a lipid or lipoid according to the above systematization. The recent development of the biochemical methods of investigation has put into limelight many biochemical processes by considering them as isolated metabolic entities. Most of them were seen to result from the intervention of enzymes upon more or less specific sub¬ strata. One of the principal objectives of the actual pharmacodynamic studies is to correlate as directly as possible, biological effects of different agents to specific metabolic processes, most of them corresponding to a change in an enzymatic process. This approach, while very interesting, would not take into consideration the important role played by the non¬ specific activity of lipids and lipoids. These nonspecific influences through changes in the lipidic system induce different changes in different metabolic processes. A nonspecific change in membrane permeability will affect many enzymatic processes. It explains the existence of similar influences exerted upon these processes common to agents which have nothing more in com¬ mon than their lipoidic properties and the presence of a positive or a nega¬ tive character of their polar group. It is this character which binds an effect to the nonspecific intervention. This so-systematized analysis has thus per¬ mitted to separate the biological activity of the lipids and lipoids, the more specific from the lesser influences, and correlate each one to a proper or common character of the agent. This view has amply simplified the study of the pharmacodynamic intervention of these substances.

OTHER CONSTITUENTS In addition to the chemical elements and lipids, other constituents have been studied from the dualistic point of view. Although the other constit¬ uents have received less emphasis, interesting information has been ob¬ tained.

Google

UNIVERSITY OF MICHIGAN

LIPIDS

AND

LIPOIDS

/

169

Amino Acids Amino acids have been separated into groups based upon their effects at different levels. The first group includes the simple amino acids. In these members the portions of the molecule which are added to the ampho¬ teric amino acid group, are usually electrically neutral. The amino acids polymerized through the amphoteric group serve as building materials for the bigger protein molecules. They have appeared to be inert without effects upon the different levels. Beyond these simple amino acids, are two groups, energetically active, which have a second energetic center with a negative or positive character in their molecules. While the amino acid group serves to make these substances parts of higher proteins through the same bonds of amino acid groups as the simple members, it is the other energetic center, with acid or alkaline character, which confers upon these amino acids a positive or negative character. We studied effects, at different levels, of arginine, lysine and histidine, which are members of the group with alkaline centers; of glutamic and aspartic acids which have acid centers; and of methionine with a thiolic center. Like for the lipids, the last two groups have shown similar prop¬ erties, but opposite to those of the members with alkaline centers. The na¬ ture of their intervention appeared evident through the interesting opposite effects exerted upon microbes. Cultures of B. subtilis in broth containing members of one or the other of the antagonistic groups show characteristic changes. Unlike controls in which the long chains of microbes remain iso¬ lated, the microbes were seen to be kept together in media with alkaline amino acids, forming a consistent gelatinous mass separated from the medium. In broth with acidic or thiolic amino acids, the microbes re¬ mained separated or formed very small aggregates. This appeared interest¬ ing when we considered the positive character present in alkaline amino acids, as related to the heterotropic, constructive trend, while the negative, as in the acid and thiolic members, is related to the opposite trend. We saw further the same antagonism between the influence exerted by histones and nucleic acids, the first paralleling the alkaline amino acid groups and the second the opposite group. The more manifest effect of the ribonucleic acids could be seen to take place at higher levels of the organization and possibly explains the more direct action upon the genes. We investigated the effect of the two groups of amino acids at the tissue level upon pain. Arginine, lysine and histidine displayed an analgesic effect upon alkaline pain, while glutamic acid and methionine had this effect upon acid pain. The effect could be related more to the basic tend-

Google

UNIVERSITY OF MICHIGAN

170

/

RESEARCH

IN

P H Y S I O P A THO L OO Y

ency of these substances to act through metabolic changes, than to a direct influence upon the acid-base systemic balance. The first group acts as heterotropic agents and the second as homotropic, as mentioned above. A bnormal A mino A cids Our research led us to several tentatives to define abnormal amino acids and the proteins they form. One concerned their rotatory capacity. The naturally occurring amino acids are all levorotatory. However, the organism constantly has enzymes able to attack dextrorotatory amino acid members as if it would have to be prepared to encounter and destroy them. Such dextrorotatory members can be conceived to appear on a statistical basis as the result of the resonance process seen to occur in all the synthesis in nature. The intervention of specific enzymes against them would have the aim to control their existence and especially to prevent their intervention in further evolution. In a work hypothesis concerning the cancerous process, we considered that their persistence and especially their participation in forming hierarchic entities would correspond to the specific abnormality characterizing this condition. In another work hypothesis which concerns also cancerous processes and which we will discuss later, abnormal proteins are thought to appear as a result of the bond of a carbamic radical (295) to the amino acid group. The resulting cyclic formation having the characteristic NCNC group in it, would correspond to abnormal amino acids which would represent the primary characteristic formation of the cancerous condition. (See Chapter 11, Note 1) Carbohydrates—Glucose acts as an anti-fatty acid agent, possibly be¬ cause of the glyceryl compounds resulting from its metabolism. We have studied it in opposition to the respective acids—gluconic, glucuronic and saccharic. Glucose has an analgesic effect, although limited, upon pain of an alkaline pattern, and an opposite effect upon pain of an acid pattern. The acid group has an opposite effect upon pain. This could be corre¬ lated with the changes toward acidosis seen in the local pH of the lesions. A manifest change toward acidosis was seen under the influence of glucose in the second day wound crust pH. We have noted previously the role played by glucuronic acid as an agent with anti-positive-lipid activity. We believe that it is largely through this mechanism that it favorably influences acid pain, having an indirect action similar to that of fatty acids.

Digitized by

Google

UNIVERSITY OF MICHIGAN

CHAPTER

DEFENSE

multiple factors are responsible for abnormal conditions, and that these factors can be systematized according to the concepts presented above, throws new light on a specific aspect of the relationship between the different entities and the environment when this tends to alter their characteristic organization. This response is concretized as the defense against the noxious. The analysis of this defense has been facilitated by emphasizing the relative independence of the entities forming the complex hierarchic organism, the dualistic patterns of response, and the critical role of the lipids as well as of proteins. Abnormal processes in an organism’s defense system may be better understood when they are compared to those corresponding to normal physiological processes. For this reason, we start with this last aspect. The direct intervention of a noxious agent upon a biological entity can be characterized by its tendency to induce heterogenization, through an al¬ teration of the entity’s constituents or the relationship between them. This, in turn, affects one or more of the constants that characterize the entity. The ensuing defense response is directed ultimately at restoring the altered constants to their normal values. Involved in a first stage of defense are those very factors which nor¬ mally maintain the constants, the factors which induce the oscillatory dynamic balance. As a first response, they become exaggerated. Such exaggeration, which takes place successively for the opposite phases, re¬ solves many slight noxious interventions without clinical manifestations. Through a damping movement, the exaggerated oscillations soon return to normal. If the normal constants are reestablished, the phenomenon can be considered to be a physiological response. But if the alterations induced by the noxious agent persist, an abnormal The recognition that

171

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

172

/

RESEARCH

IN

PHYSIOPATHOLOGY

condition results. Indeed, in this case the exaggeration of oscillatory move¬ ment can be so great that an abnormality may result even from this ex¬ aggerated attempt of the entity to reestablish normalcy. In faot, offbalances are induced by just such changes which often represent, by themselves as will be seen later, one of the major immediate factors inducing the abnormalcy. As long as an abnormal condition is not resolved, the biological entity will try to utilize new means in order to reestablish the normal bal¬ ance. If the constants disturbed by the noxious intervention are funda¬ mental, or if the changes resulting from the defense mechanism itself are too great, death of the entity will result. As expected, responses will differ according to the level to which an affected entity belongs. However, despite the many differences related to levels, a common and relatively simple pattern can be recognized when manifestations occurring at different levels as the result of the noxious intervention are compared and referred to the basic pathological concepts already noted. Most of the information about this simple pattern was originally ob¬ tained by studying responses at the systemic level. Blood was particularly suitable because of its availability, its multiple constants and manifest ca¬ pacity to conserve them, and particularly because of the facility with which noxious agents could be induced to act upon it. The intervention of a noxious agent able to change the energetic bal¬ ance of blood sets in motion immediately a group of successive processes which may or may not be clinically apparent, depending upon their in¬ tensity. They have been described as hemoclasia by Widal and hemo-shock by many authors. Although widely investigated, the mechanism did not appear clear. From our studies, we have arrived at certain conclusions which we will briefly present here. Diphasic Phenomenon

As a noxious factor, we used an intravenous injection of killed microbes or of a colloidal suspension of a metal. Within a few minutes, a group of changes occurred. They were revealed through a series of analyses made at very short intervals. (Note 1) The changes were found to affect most of the blood constituents. The most characteristic change in our opinion is a leucopenia which especially affects the granulocytes. With it, there is a lowering of serum antitryptic power; a decrease of serum albumin; appear¬ ance of degradated proteins, esterase and amylase; increase of free fatty acids; and a lowering of coagulability with reduced clot retraction. Clini¬ cally, these changes are accompanied by hypothermia and hypotension.

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

DEFENSE

/

173

Together they represent what we will call the “negative phase” of the im¬ mediate response. This group of changes represents, in fact, only the first part of a di¬ phasic phenomenon. The negative phase is usually followed by a second and opposite one which we call the “positive phase” of this immediate response. It results from the tendency of the body to correct, and even over-correct, the changes occurring in the first phase. After hypothermia and hypotension, hyperthermia and slight hypertension follow. At the same time, the number of granulocytes increases, as does the antitryptic power of serum and its albumin content. The serum appears richer in free sterols. Blood coagulability and clot retraction also increase. After moving rapidly to a peak, all these values return slowly to normal. The existence

Fig. 75. Diphasic response in the defense. The intravenous injections to a normal indi¬

vidual of a foreign material such as of a suspension of killed microbes or of a colloidal metal induces a typical response which corresponds to the hemoshock. A diphasic curve seen in most of the analyses characterizes the occurring variations. The curve presented corresponds to the total number of the blood leucocytes. A parallel diphasic curve is seen for other blood analyses such as clot retraction, albumin content of the serum, and antitryptic values of the serum. Similar diphasic curves, but opposite in sense, are seen for blood coagulation time, amount of amylase and esterase in the serum, amount of K+ in the serum, and for the amounts of proteoses and peptones

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

174

/

RESEARCH

IN

PH YSIOP A THOLOGY

of two phases can be recognized in all the changes occurring in hemoshock. (Fig. 75) In trying to correlate the multiple changes taking place, it is the lysis of leucocytes, especially granulocytes, which can be considered of primary importance in the development of hemo-shock. This is evident from the relationship between granulocytopenia and the intensity of the diphasic phenomenon. The administration of morphine or other opium derivatives to an individual, prior to the application of the noxious factor, will reduce or suppress the granulocytopenia together with all the manifestations. (Note 2) Intensive physical exercise concomitant with the application of

the noxious factor will increase the granulocytopenia parallel with all the manifestations of hemo-shock. (Note 3) According to our hypothesis, lysis leads to liberation of proteolytic enzymes which may be present as such or may be present in precursor form in the leucocytes. And it is the intervention of these enzymes which reduces the antitryptic power of the blood and, by digesting blood con¬ stituents, lowers the amount of albumin present in the serum, and induces a parallel increase of products of protein hydrolysis. The increase in am¬ ylase as well as in esterase present in blood is related to the other hydro¬ lytic enzymes liberated in this phase, and is also probably correlated with leucolysis. The esterase acts hydrolytically upon the neutral fats present and this would explain, at least in part, the liberation of free fatty acids seen in this phase. In the changes corresponding to the first phase, digestive effect of these enzymes upon the blood constituents can be recognized as being one of the most important intervening factors. We confirmed the correlation between these changes and leucolysis not only through their parallel variations, as mentioned above, but also through in-vitro experiments. Lysis of leucocytes resulted in liberation of hydrolytic enzymes. An exudate rich in granulocytes was obtained by injecting sterile broth, or an aleuron suspension, into the pleura of rabbits. To this exudate, removed through pleural puncture, a small amount of a colloidal silver-protein preparation (Collargol 0.1%) was added and the preparation maintained at 38°C. This was seen to induce the appearance of vacuoles in the leucocytes, following the phagocytosis of silver grains. The vacuoles were observed to grow rapidly to huge dimensions followed by bursting of the leucocytes. (Fig. 76) Analysis of the pleural fluid treated in this manner has shown the same change as those seen in the first phase of hemo-shock: lowering of anti¬ tryptic power with a decrease in albumin content, increase in products formed by partial digestion of proteins, appearance of amylase and ester-

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

DEFENSE

/

175

ase, and an increase of free fatty acids. There were also the same nuclear “shadows” as encountered in large amounts in the circulating blood at this phase. The increase of the potassium content of serum seen in this phase, and the increase found also in the supernatant part following centrifuga¬ tion of the exudate to which Collargol had been added, represents a further confirmation of the role of leucolysis in this first phase. These data enabled us to consider that the mechanism through which the blood tries to com¬ bat the intervention of a noxious agent corresponds, in the first phase, primarily to a lysis of granulocytes followed by hydrolytic digestion.

ProteinSilver Granules Moral Granulocytes

O O nuclear shadow Leucocytes treated with Collargol

Fio. 76. Drawing of the changes induced by a colloidal suspension of silver proleinale upon leucocytes. The leucocytes were obtained by injecting broth intrapleurally to rabbits. Silver proteinate was added to the suspension of leucocytes and the changes observed in a microscope heated chamber maintained at 38°C. The phagocytosis of the silver proteinate leads first to the appearance of this substance as intracellular granules, followed by the formation of vacuoles. As these grow to a huge size the cells burst. The nucleus remains as nuclear shadow.

The second phase, which would correspond to efforts to correct the exaggerated effects of the first digestive phase, involves largely a mobiliza¬ tion of reserves of those blood constituents which were altered during the first digestive phase. The spleen pours a part of its stored blood into the cir¬ culation. The richness of spleen in reticuloendothelial cells explains the liberation of sterols which is seen during this second phase. This is recog¬ nized by the fact that, at this time, the spleen efferent blood is richer in sterols than the afferent blood. Other constituents come from intercellular and lymphatic spaces. This mobilization, characterizing the second phase of hemo-shock, appears to be achieved in large part mechanically, through a direct intervention of the vegetative nervous system inducing the con¬ traction of the smooth muscular fibers, as seen during chill, which marks the beginning of this second phase. Fever which follows, is in part, due to the sterols liberated largely by the reticuloendothelial system.

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

176

/

RESEARCH

IN

PHYSIOPATHOLOGY

If this hemo-shock, in spite of its frequently violent clinical manifesta¬ tions, resolves the effects of the noxious intervention upon the blood, it can be considered to be, to a certain degree, a physiological response. It amounts to an exaggeration of the oscillatory mechanism through which the characteristic constants of the blood are maintained. By employing the hydrolytic enzymes stored in the leucocytes, the blood tries to resolve the influence exercised by the noxious factor, digesting and thus breaking down either the factor itself or the results of its direct intervention. Acting upon blood constituents, the noxious agent often induces the appearance of micelles bigger than those normally circulating. The fatty acids liberated by hydrolytic enzymes would insure, in the first place, a higher boundary permeability, thus permitting the passage through the capillaries of sub¬ stances otherwise barred. At the same time the fatty acids bind the antigen in a lipidic complex. In the second phase, the organism tries to repair damages caused by the exaggerated digestive process or by the intervention of fatty acids. If the organism is able to resolve through a successful diphasic reaction the changes induced by the noxious agent, it returns to normal.

Prolonged Hemoshock Inability of the organism to resolve the noxious intervention through the mechanism involved in the diphasic phenomenon leads to abnormal prolongation of one phase or another. If it is unable to destroy the noxious factor in the first phase or to mobilize the repair process in the second and thus correct the damage induced by the first phase, the organism re¬ mains in a prolonged first phase of hemo-shock. If the second phase is quantitatively or especially qualitatively inadequate, the organism remains in a prolonged second phase, continuing to try to resolve the offbalance by a quantitatively greater mobilization of the otherwise qualitatively inade¬ quate weapons which are at its disposal. It is the predominant intervention of the lipids which characterizes these extended phases. We wish to note again that the fatty acids intervene in the prolonged first phase while anti¬ fatty acid agents, especially sterols, are active in the second. The adrenals play a particularly important role in the immediate and prolonged defense process. In the first phase, the increased amount of fatty acids with four or more double bonds found in blood and in the organism in general appears to come from the adrenals, which are usually extremely rich in these substances. In an exaggeratedly intensive prolonged first phase, we found small reddish adrenals practically devoid of fatty acids. This occurrence, together with the concurrent increase in fatty acids

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

DEFENSE

/

177

in the blood, relates these changes in fatty acid content of the blood largely to a liberation of the adrenal fatty acids into the circulation. Another im¬ portant factor for the prolonged first phase appears in the intervention of lymphocytes able to induce a lysis of compounds of very high fatty acids such as present even in waxes. (Note 4) A lymphopenia corresponds to the prolonged first phase. In the elevation of the amount of anti-fatty acid agents in blood, characteristic of the prolonged second phase of the di¬ phasic phenomenon, the adrenals seem to intervene again providing a portion of the increased circulating sterols. The exaggerated manufacture of sterols can be attributed to the reticuloendothelial system in general. Granulocytosis and lymphocytosis occur in this prolonged second phase. The intervention of sterols, which are relatively simple steroids, can ex¬ plain the clinical manifestations such as fever, which characterize the pro¬ longed second phase, since fever can be induced by the administration of large amounts of sterols. We can separate, from the point of view of its manifestations, the immediate diphasic hemo-shock phenomenon with a short evolution, from the more prolonged forms. While the former, if not too exaggerated, would correspond to a physiological phenomenon, the latter is always abnormal. In the former, the principal intervention is that of hydrolytic enzymes; in the latter, lipids play the most predominant role. Pathogenically, each phase of the diphasic phenomenon, if unable by itself to resolve the im¬ mediate problem, will be followed by a corresponding lipidic predominance. The result may be either one of the two phases, with fatty acids or sterols predominant. We call this entire response “the antiheterogeneous reaction" of the defense, separating its diphasic manifestations into immediate hy¬ drolytic and prolonged lipidic stages. Antiheterogeneous Reaction Although, in the prolonged lipidic stage, a certain specificity for par¬ ticular antigens can be recognized, the antiheterogeneous response in general represents rather a nonspecific effort of the organism to resolve the problems caused by the presence of any heterogeneous factors as such. Before going further, we want to emphasize some important charac¬ teristics of this antiheterogeneous response related to organization. The catabolic processes present in the first phase appear to result in part from the direct hydrolytic process and in part from the biological intervention of the products of hydrolysis, especially fatty acids. The hydrolytic en¬ zymatic process is homotropic in nature by definition, as it breaks down different constituents, liberating groups with anionic and cationic character.

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

178

/

RESEARCH

IN

PHYSIOPATHOLOCY

Enhancing the catabolic character of the first phase processes are the anionic groups which appear to have a predominant role. The second phase, a reparative one, is anabolic and therefore, heterotropic in char¬ acter. The study of the antiheterogeneous response emphasizes another fun¬ damental characteristic of the processes. A basic difference exists between the direct effects induced by the intervening agent and those resulting from the defense processes themselves. A direct effect of a noxious intervention corresponds to heterogenization of the constituents. Some changes will appear through this heterogenization itself, others through the defense processes which represent the response of the organism to the heterogeniza¬ tion. While the first corresponds to a direct action, the last is catalogued as antigenic, its manifestations being grouped as defense processes. The same substance can have a direct action and an antigenic one revealed principally through the manifestations which it induces. A direct action can be noted instantaneously if the changes induced are sufficiently in¬ tensive. The antigen effects always require a certain time before mani¬ festations appear. This time can range from a few minutes for the first enzymatic response to hours or days for the prolonged response. An important feature of the prolonged stage is that it persists as long as the noxious agent is present. This is evident in cases in which the noxious agent can be suppressed through external intervention. For ex¬ ample, with suppression of microbial activity by antibiotics, the corre¬ sponding clinical condition disappears. Of more interest is the effect of antimicrobial and antitoxic immune sera. Administration of a specific serum, if it can neutralize the noxious agent, produces a curative effect at this stage. In a short time, symptoms disappear and the organism reverts to normal. Although nonspecific, the prolonged antiheterogeneous reaction shows such a straight correlation with the presence of the antigen as to make us designate this stage as primary or toxic. In this stage, the organism reacts with clinical manifestations of disease if the antigen is capable of inducing sufficient noxious changes; if not, there are no clinical manifesta¬ tions. Persistence in the organism of an antigen beyond the rapid diphasic phenomenon indicates, in general, an incapacity of the organism to achieve its disposal successfully. The need for more complex means to combat the antigen becomes imperative. With or without clinical manifestations—that is, even without a primary toxic stage of the disease—as long as the antigen has not been fully neu¬ tralized, the organism will still try to resolve its intervention and return to normal, resorting to other means. It will produce antibodies with a cer-

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

DEFENSE

/

179

tain degree of specificity toward the antigen. Two kinds of antibodies will be manufactured and will differ in their fundamental characteristics, the time of their appearance, and their role in the defense processes. Coagulant Antibodies

The first group of antibodies have a characteristic property. Together with the antigen, on which they fix with a degree of specificity, they form highly energetic complexes. This is manifest in a marked tendency to bind together such complexes as well as constituents of the blood and form huge aggregates. When such antibodies are produced for, and act against, a specific microbe, agglutination results. Conglutination, precipitation and flocculation occur when similar antibodies act against other antigens. Due to their tendency to establish antigen antibody complexes resulting in huge formations, these antibodies are generally grouped as coagulant antibodies. Although the coagulation characteristic is not demonstrable in vitro for all antibodies in this group, we use the term “coagulant antibodies” for didactic purposes. The huge complex formation resulting from the binding of coagulant antibodies with an antigen can appear as a precipitate, agglutinated microbe or conglutinated red cells. Once established, this formation represents a new heterogeneous entity of much larger dimensions than the antigen alone. As such, it becomes by itself a new noxious agent for the organism which consequently reacts against it. The organism utilizes the same proc¬ esses against this noxious antigen-coagulant antibody complex as it uses for any heterogeneous agent, with the same immediate diphasic or pro¬ longed mechanism. Teleologically, the formation of coagulant antibodies can be interpreted as an attempt of the organism to defend itself anew against the antigen. The antigen, this time fixed through these antibodies in a new and more noxious formation, will once again incite the nonspecific defense mecha¬ nism. First there will be the antiheterogeneous response with its diphasic phenomenon and, if once more this is not effective, a prolonged new lipidic intervention will follow. If the quantity of heterogeneous formations is great, the first phase of the diphasic phenomenon can be so severe as to cause death in a few minutes. If less severe, this first phase is followed by the second, with chills and high temperature. As in all the antiheterogene¬ ous reactions, the organism tries to combat the presence of the noxious factor—in this case, the flocculate produced by the antigen-antibody bond —attempting to digest it through hydrolytic enzymes or to neutralize it through constituents brought in during the second phase of the diphasic

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

180

/

RESEARCH

IN

PHYSIOPATHOLOOY

phenomenon. If it fails, the abnormal prolonged form of this response follows with characteristic lipidic liberation. In terms of biological meaning, the formation of coagulant antibodies represents a new chance for the organism to resume the fight against anti¬ gens by using the same fundamental means, the antiheterogeneous re¬ action. However, since the new agent, the antigen-antibody complex, is much more noxious than the antigen alone, the intensity of the response will be much stronger and the chances of disposing of the antigen will be greater. Allergic Reaction The generic term “allergic” is reserved for the entire group of processes in which a coagulant antibody takes part. The reaction now against the antigen-antibody complex is a typical antiheterogeneous response. A fundamental difference exists, however, between the antiheterogeneous reaction in the primary toxic stage and the reaction which occurs when the heterogeneous factor is a complex antigen-coagulant antibody usually with more noxious character than the antigen alone. It is the nature of the antigen-antibody, the result of the bond of the coagulant and the antigen, which gives it the allergic character. This faot explains why, although we can possess specific immune serum able to neutralize an antigen alone, this will not influence the allergic response. Already bound to a coagulant antibody, the antigen cannot be bound again and consequently neutralized by another antibody. The specific neutralizing serum will have no effect upon the antigen-coagulant-antibody complex already formed and consequently will have no effect upon the processes induced by this complex. The immune serum does not influence the allergic manifestations which represent the response to antigen-coagulant-antibody complexes. This would theoreti¬ cally explain the favorable effects of a specific serum upon a condition which is in the toxic primary stage, where the antigen intervenes as such, and the lack of such favorable effects in the allergic stage, where the anti¬ gen is representing only a part of a complex new noxious formation. This mechanism would also explain why the same immune serum, al¬ though without curative effect upon the allergic stage of a condition, will have preventive activity. Before the onset of the allergic stage—that is, before the coagulant antibodies have appeared—the active immune serum will bind and neutralize the antigens still free in the organism. Under these conditions, when coagulant antibodies appear, the antigens are no longer available to be bound by them to form the noxious antigen-coagulant-antibody complexes. Without curative action, immune serum is effective as a

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

DEFENSE

/

181

preventive only when administered prior to appearance of coagulant anti¬ bodies. An important factor for the allergic response is the time of liberation of coagulant antibodies. Generally, a period of 6 to 8 days is required. Under special circumstances, as in cases in which the organism has manu¬ factured the same antibodies in the past, the time necessary for their ap¬ pearance is reduced even to 4 days. In other cases, for certain antigens or for older subjects, the time may be as long as 14 days or even longer. For certain antigens, or under special circumstances, the body appears unable to make coagulant antibodies at all. In that case, no allergic manifestations appear. It must be emphasized that antibodies will be liberated even if the anti¬ gen is no longer present. The presence of antibodies alone does not give rise to any reaction and their appearance will pass without any manifesta¬ tions. However, they can persist under certain circumstances for months or years and become a potential source of abnormality. At any time if the same antigen becomes present in the body, the coagulant antibody will form the allergic bond with it. The body will then react against the newly formed complex with an antiheterogeneous response. If this occurs in the blood or central nervous system, it can appear as an immediate violent re¬ action which corresponds to anaphylactic shock. It is the intensive first phase of the diphasic phenomenon which kills in anaphylactic shock. Such shock can be easily produced in animals as passive anaphylaxy by making coagulant antibodies and antigens available concomitantly in the blood. Lipido-proteic A ntibodies Analysis of allergic antibodies indicates that they have two constituents, lipids and proteins. Electrophoretic analyses reveal that they are displaced mostly as beta globulins. Experiments show that such lipido-proteic anti¬ bodies lose their activity if broken into their constituents, neither the lipid fraction nor the protein alone being able to bind the antigen. The study of the lipido-proteic antibodies, brought us back to consider the role of the lipids in the immediate or prolonged first phase. Most, if not all the natural antigens have lipids and lipoproteins in their structure. As we have seen above, some of the fatty acids induce defense responses. The administration of fatty acids is followed by a leucopenia—especially a lymphopenia; administration of sterols, by a hyperleucocytosis. Some fatty acids, such as those obtained from the tubercle bacilli, induce characteristic lesions such as giant cells. There are both naturally present lipoproteins and those resulting from the bond of the body’s freed fatty acids to the

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

182

/

RESEARCH

IN

PHYSIOPATHOLOGY

antigen, which seem to act as specific antigens, inducing the appearance of coagulant, allergic antibodies. Experiments, which we will discuss below, have shown that, while the specificity of the antibodies is highly related to the protein fraction, the allergic or immune character of the resulting re¬ sponse is due to the fact that lipido-proteins are involved in these proc¬ esses. The injection of the product resulting from the action in vitro of the acid lipidic constituents of an organism upon proteins of another species acts as an antigen inducing the early appearance of coagulant antibodies. The repeated injections of the product obtained through the action in vitro of foreign lipoacid fractions of various origins upon different body proteins also induces allergic response. Just as we have connected the appearance of the first diphasic phenomenon to hydrolytic enzymes and the prolonged form of the antiheterogeneous defense mechanism to the intervention of lipids, we relate the allergic body defense to the intervention of lipidoproteic formations. The allergic stage of defense thus could be considered to be a lipido-proteic defense response against lipido-proteic antigens. Neutralizing Antibodies

The unsuccessful fight of the organism against an antigen through the diphasic, lipidic or allergic responses often can evolve further, making use of a more effective measure which corresponds to another kind of anti¬ body, different from the coagulant type. The characteristic of this second type is that it forms, specifically with the antigen against which it is manu¬ factured, a new kind of bond, an antigen-antibody-complex, this time en¬ tirely nonnoxious to the organism. This complex is energetically so balanced as to correspond to the constants of respective levels of the body where it occurs. Through this new bond, the antigen is biologically neutral¬ ized in the sense that the resulting antigen-antibody-complex is entirely harmless. This type of neutralizing or immune antibody usually appears on or after the 15 th day following the moment when the organism has started to organize its defense against the antigen. It can occur whether the antigen is still present or not and whether it is free or bound to coagulant anti¬ bodies. It represents the best means through which the organism opposes the influence exercised by an antigen. The appearance of the neutralizing antibodies corresponds to the last stage, the immune one, in the defense mechanism. If the antigen has produced a clinical condition, the neutral¬ ization of the antigen by the new antibody results in the slow disappearance of morbid manifestations and a progressive return to normal. With or with¬ out prior clinical manifestations, the presence of the neutralizing antibody

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

DEFENSE

/

183

in the organism provides a potential weapon to prevent the same antigen from again causing trouble. This has led us to identify this part of the defense reaction as the “immune stage” of the defense mechanism. The action of these neutralizing antibodies has been demonstrated be¬ yond doubt through passive immunity. Their administration confers pro¬ tection against the antigen. This action is limited to the antigen so long as it is not bound by another antibody. Clinically, neutralizing antibodies have a curative value if the antigen is present, inducing the primary-toxic response. They have, also a preventive effect upon the allergic form of the disease if they are administered before the appearance of the coagulant antibodies. Neutralizing antibodies are globulinic in nature. They are displaced in electrophoretic analyses as gamma globulins. Isolated as pure globulins, they do not lose their activity. This would differentiate them from the coagulant antibodies which, as previously noted, are lipido-proteinic in nature. The defense resources of organisms against antigens thus can be di¬ dactically separated into four fundamentally distinct groups: enzymatic hydrolytic, lipidic, lipoproteinic and proteinic. They correspond to distinct stages from the point of view of reactions induced and biological meaning. The first represents a primary, direct, immediate response characterized by a rapid nonspecific digestive process and followed by the exaggerated mobilization of repair processes. If the immediate response is inadequate, a second stage as a prolonged lipidic defense follows. Although it has a cer¬ tain degree of specificity, this last response is still directed against a hetero¬ geneous constitution of the agent as such. If unsuccessful in inactivating the agent, all these responses are followed by another defense stage in which action is taken against the antigen through more specific coagulant lipido-proteinic antibodies and through the antiheterogeneous reaction to the resulting complex. With the last stage, which is characterized by the intervention of proteinic neutralizing protective immune antibodies, the fight against the antigen is usually concluded successfully. Table XI, below, summarizes this systematization of the defense response. Defense and Hierarchic Levels The above changes represent, in a schematic manner, what happens when a noxious agent acts directly or indirectly upon blood. The same basic patterns of defense, the substances used and the processes involved can be found at various hierarchic levels. It is easy to see that, with such a

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

o

O

’5o U j* rj

£?»

l

Google

Original from

UNIVERSITY OF MICHIGAN

PHARMACODYNAMIC

ACTIVITY

(PART

TWO)

/

409

result from the binding of molecular oxygen, while the epoxides result from binding of atomic oxygen, both under abnormal conditions. Peroxides were administered as adjunct agents in cases highly refractory to therapy with lipoids having negative polar groups. In preliminary experiments, it could be seen that a certain condition was necessary to influence the desired processes. The peroxide used has to be a lipoid if it is to have influence upon the lipidic system. Some lipoidic peroxides were prepared, and their therapeutic value is still under investigation. The influence of lipoidic epoxides upon the process of carcinogenesis also is under study. Peroxidases It has been previously noted that hydroperoxides resulting from the oxidation of mono- and polyunsaturated fatty acids are found normally in the organism, but peroxides appear only under abnormal conditions and particularly when abnormal fatty acids intervene. The manifestations of the type D offbalance in its oxygen phase thus can be attributed to the presence of peroxides. Biologically, the intervention of peroxides would be counter¬ acted by peroxidases and catalases. It was interesting to study a clinical curiosity which could be connected with a probable intervention of peroxi¬ dases. In several patients with frequent headaches, whose analyses showed a typical acid pain pattern, pain was repeatedly intensified or even induced by eating pears. No other fruit had such effect; some had the opposite effect. This led us to consider that the pain intensifying action was not due to an acid-base change. The large amount of peroxidases in pears led us to isolate this enzyme in order to study its direct influence upon pain. Peroxidase could be obtained from pears in relatively small amounts, and showed reduced activity upon peroxides even in vitro. We were able to prepare much larger quantities of a highly active peroxidase from horse radish. After being purified and tested for antiperoxide activity, preparations were administered orally to patients with acid or alkaline pain pattern. While the former was definitely intensified, there was no relief of the latter. It seemed that the effects obtained through the administration of isolated pexoridases were the same as those obtained when pears were eaten. Antioxidants The relationship between fixation of oxygen and chlorides has led to the study of antioxidants capable of acting in situations of abnormal oxi¬ dation. It was hoped that these substances also would be able to influence the fixation of chloride ions.

Digit1 itrU

by Google

UNIVERSITY OF MICHIGAN

410

/

RESEARCH

IN

P HY S I O P ATH OLOO Y

We have utilized several groups of known antioxidants, starting with manganese compounds, such as inorganic salts, and later binding these to lipids. It is too early yet to draw any definite conclusions from animal ex¬ periments, and we have not used the compounds clinically. However, our studies up to now do not show any influence that could be interpreted as sufficient to warrant hope that these compounds can control the fixation of chlorides on fatty acids. In the same series of researches, other antioxidants—some of them used for the preservation of edible fats and others for the control of oxidation in other substances such as rubber—were tried. We investigated the in¬ fluence of tocopherols, the natural antioxidants for vegetable oils. Alpha tocopherol in doses of 100 mg. was administered several times a day to patients having symptoms and signs corresponding to an intervention of abnormal fatty acids. A decrease in the intensity of pain of an alkaline pattern was observed. Along the same lines, we investigated the influence exerted by maleic acid, used to prevent the rancidity of edible fats. In proportion of 1/10,000 this acid conserves these fats for months. Curiously enough, maleic and citraconic acid have shown an influence upon the abnormal manifestation of the type D. For these reasons we utilized these two acids—maleic and citraconic— as anti-D agents. In one study, the acids were injected intravenously in proportion of from 0.1 to 1 mgr./lOO cc. of saline. In others, the sodium salts of the acid were used, while in still others the butyl esters were pre¬ pared and administered intramuscularly in oily solutions. For the present it is difficult to judge the effects obtained. All the above mentioned attempts were made on the basis of a direct action upon fatty acids and other lipoidic constituents with negative polar groups which intervene in inducing offbalances. For the present, it seems that no single agent can resolve the problems that result from the plural intervention of various abnormal fatty acids at the different levels. The use of various agents acting selectively at the different levels involved seems to be the only available path by which therapeutic intervention against the multiple manifestations at different levels can be accomplished. Before going further, we thought it useful to have a synoptic view of this special part of the pharmacological activity as obtained through the study of the influence upon pain and the systemic level analyses as seen in humans. To this we added the effect seen upon tumors in humans. Tables XX and XXI which give this information in a very condensed form, were limited to the most important agents tested for each group studied. The effects are indicated as clinical results also for the facility of the presentation.

Dig

Google

UNIVERSITY OF MICHIGAN

PHARMACODYNAMIC

ACTIVITY

(PART

TWO)

/

411

Table XX Clinical Results With Agents That Act Upon The Offbalance Type “A** 1

Agent

Group

Fatty Acids Saturated

Polyunsaturated Mixtures from organs M from cod liver oil Irradiated Conjugated a—OH Polyhydroxy Chloro-derivatives

Systemic Level

Pain

None Slight

None Fair

il

Good Fair

H

Influences Exerted Upon Tumor None Some, not consistent, not persistent 44

44

44

Fair, not consistent, not persistent

ll

44

44

II

44

•i

44

44

44

44

None Slight Fair

None Slight Fair

Oleic

Slight

None

Croton ic

Slight

Slight

Propionic Heptylic

Good Good

Good Slight

Good None Slight

Good None Slight

Fair

Fair

Slight Fair

Fair Fair

Fair

Slight

Perselenide

Fair

Good

Perborate Perchlorate

Fair

Fair

M

44

Hormones

Testosterone

Slight

None

Mustards

Sulfur mustard

Fair

Fair

Hydrines

Epichlorohydrin

Fair to good

Slight

Aldehydes

Sulfur Thiosulfates Compounds S. Colloidal

Mercaptans Hydropersulfides Methyl thioglycolate Tetrahydronaphthalene persulfides Selenium Alkyldiselenide Compounds Peracids

Digitized by

Google

None None Some, not consistent, not persistent None Slight, not consistent, not persistent Fair Fair Fair None Good, consistent, persistent Fair, not consistent, not persistent 44

44

44

Good, consistent and persistent Good, consistent, persistent 44

44

44

Some, not consistent, not persistent Seldom, not consist¬ ent, not persistent Fair,

M

Fair, consistent, persistent

Original from UNIVERSITY OF MICHIGAN

412

/

RESEARCH

IN

P H Y S I O P A TH OL OG Y

Table

XXI

Clinical Results With Agents That Act Upon The Offbalance Type

“D" Influences Exerted Upon Tumor

Systemic Level

Pain

Fair

Fair

44

44

*4

44

44

44

44

44

44

44

44

44

Butanol Pentanol Heptanol

Good Fair

Good Fair Slight

44

44

44

Octanol

Slight

44

44

44

None

None

Glycerol

Slight

Good

Inositol

None

None

Slight

Slight

44

44

44

Fair

Polyconjugated Croton ic Ricinoleic Salicylic

44

44

44

Slight Fair Slight

Hormones

Estrogens

44

“

A mines

Aminobutanol Hexylamine Heptylamine Glucosamine

44

Fair

44

44

44

44

44

44

44

44

Good Good

44

“

“

Agent

Group Sterols

Cholesterol Insapon. fraction of organs of eggs of milk

Alcohols

Seldom, not consist¬ ent, not persistent

A liphatic saturated

Octanediol Nonanol

44

Fair, M “ Good, consistent, per¬ sistent Fair, not consistent, not persistent Slight None

Polyalcohol

Good, consistent, per¬ sistent None

Unsaturated

Oleic Linoleic Polyunsaturated

Nicotinic acid deriv. Metals

Halogen

Niketamide Iron Mercury Bismuth

44

44

None None Slight, not consistent, not persistent Fair, " M 44

44

44

Slight, Fair,

M "

•* “

1 Slight,

“

“

Slight

Fair, None

44

Good

None

Fair

Slight None

None

44

44

44

44

44

Iodine

Slight

Fair

44

Oxygen

None

Good

Digitized by

Goo

None

Original from UNIVERSITY OF MICHIGAN

CHAPTER

14 THERAPEUTIC APPROACH

BIOLOGICALLY GUIDED THERAPY

ThE studies previously described have identified many factors in¬ volved in the pathogenesis of abnormal conditions and have shown that there are similar factors which also govern the pharmacological activity of various agents. Out of this peculiar relationship between abnormal condi¬ tions and agents has evolved a therapeutic method which is fundamentally different from methods in common use. In conventional therapeutic efforts against disease—in chemotherapy of cancer for example—methods as standardized as possible are sought. The goal is to find agents capable of influencing the cancer cells, if not in all tumors, then at least in tumors of the same origin. Within the limita¬ tions imposed by the general toxicity of the agent, the conduct of treatment is standardized as far as possible. The criterion of value of a treatment is its ability to overcome individual variations. In our approach, in clear contradistinction, the effort is to influence the complex condition as it is present at different levels of the organization. It corresponds to treatment individualized as far as possible. Therapeutic efforts are guided in all their aspects—choice of agents, doses to be used— by existing manifestations with their multiple quantitative and qualitative variations. The fact that many of these variations occur during treatment, as a response of the organism induced by the medication itself, increases the individual character of treatment. No prediction can be made about the whole course of treatment to be used for an individual patient be¬ cause the individual qualitative and quantitative changes which occur dur¬ ing the treatment cannot be foreseen. 413

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

414

/

RESEARCH

IN

P H Y S I O P A T H O LO O Y

In this approach to therapy, the patterns of manifestations constitute the criteria which determine the choice of the group of agents, the specific members of the group, and the dosages to be used. Throughout, clinical and analytical manifestations are the major factors that guide treatment. The clear systematization of the relationship between analytical findings and therapeutic indications is vital. The fundamental offbalances, their patterns and deviations, thus guide the therapeutic approach. The nature of the fundamental offbalance, in general, indicates which of the two basic groups of agents is to be used; the patterns show which substances from these groups are desirable; while the quantitative changes in these patterns, especially under the influence of the agents, determine the doses to be administered. Any change in biological manifestations is followed by change in therapy. We call this biologically guided therapy. Through the years, although this biologically guided treatment has re¬ mained fundamentally unchanged as an approach itself, applications have evolved. Efforts have been made to find increasingly precise criteria and more efficient agents. Each of the basic physiopathological concepts has greatly helped to develop standards for the guidance of treatment. For instance, the concept of organized conditions has led to the concomitant use of several agents from the same group instead of just one. The idea for this was derived from the fact that the concomitant manifestations at different levels show relative independence; they must be influenced separately. The concept of physio¬ pathological dualism has indicated the need to use, according to the offbalance present, agents from one or the other of the two groups with antagonistic properties. The role of the lipids in dualism has underscored the importance of these substances as active agents able to induce funda¬ mental changes. The dualism of other constituents has been the basis for their use. The mechanism of natural defense has shown the advantage of using two systems simulating, in part, the kind of dualistic response which occurs naturally. As more has been learned about these basic concepts, the therapeutic approach, while it has remained fundamentally the same, has evolved and become increasingly effective. The value of biologically guided chemotherapy appears clear when we compare the effects obtained by using agents with and without the guidance furnished by this method. Several patients treated at another center of re¬ search with a well-known agent, such as a nitrogen mustard gas deriva¬ tive, have been studied. Analytical data showing the patterns present in these patients were obtained but were not used to influence the conduct

Google

unnina rrom

UNIVERSITY OF MICHIGAN

THERAPEUTIC

APPROACH

/

415

of treatment. Favorable results were seen in a few of these cases—when, by happy accident, the treatment applied was suitable both to the original problem and to the changes occurring during treatment, as revealed by analyses. In the failures, there was no such fortunate coincidence. The fundamental offbalance present called for an agent other than what was used. Or changes occurring during treatment indicated that use of the agent should be discontinued, although this was not done. We have employed the same agents in some patients but with treatment guided by individual manifestations. In some cases, the analyses indicated the need not only for more prolonged treatment, but even for the use of dosages higher than those usually accepted. In others, on the contrary, they indicated the need to reduce dosage or even to stop the treatment, although the doses were, according to the usual posology, too small. It is interesting to note that in some cases, the treatment has been stopped and restarted several times on the basis of analyses. The clinical results—immediate and long-range—were definitely better than in patients given unguided therapy. In analyzing the development of clinical applications of this form of biologically guided chemotherapy, progress can be seen to have resulted as knowledge has increased in three areas: criteria, agents used, and method of application. Criteria We have discussed the different symptoms and analytical changes with dualistic character encountered in pathological conditions. At various stages, all were considered as potential criteria for guided therapy. The value attributed to them as indications for treatment has changed as re¬ search has progressed. Some of the analytical tests have been found to reflect changes limited to a special level, while others of more general value have been found to furnish indications of broader offbalances themselves. The importance of some criteria was established only after many years. Others, once considered of major usefulness, have appeared to be less re.

liable as time went on. Body temperature, for example, in spite of the frank dualistic aspect often seen, has been considered for a long time to be in¬ fluenced by too many factors to furnish any valuable information. With the development of our research, however, temperature has become an important criterion for administration of agents but limited toward mani¬ festations at the level of the organism. Urinary specific gravity and pH; excretion of chlorides, sodium, cal¬ cium and sulfhydryl; total blood and serum potassium; and the count of eosinophiles in circulating blood—all have been used individually with the

Digitizec

i by Google

UNIVERSITY OF MICHIGAN

416

/

RESEARCH

IN

P H Y S 1 O P A T H OL OO Y

hope that they would indicate the type of fundamental offbalance present, and consequently, which group of agents should be used. Recently, how¬ ever, we have come to use these measurements rather as criteria of changes at different levels. Urinary surface tension has thus become important as an indication of the offbalance at the levels above the cells while potassium in blood indicates the offbalance at the level of the cells. Years of investi¬ gation have shown conclusively that proper criteria represent the principal condition for success in treatment by guided chemotherapy. The Agents The relative independence of the various levels involved in a condition like cancer, which originates below the level of the nuclei and progressively involves higher levels as it evolves until it terminates as a systemic condi¬ tion, necessitates having several agents chosen specifically for their ability to work at these different levels. Over the years, we have utilized many agents. The level at which they are most active, the nature of activity from the point of view of dualistic intervention, and integration of activity in the frame of the defense mecha¬ nism, represent the factors which determine the specific use of these agents. It must be emphasized that, in the study of pharmacodynamic activity, the value of information furnished by tests in laboratory animals is limited. Because changes in patterns in animals cannot be followed, we have been obliged to follow such changes in humans. Method of Application The critical role played by each level of organization in a complex condition—and the independence of these levels—underscores the urgency of applying therapeutic agents capable of acting at specific levels where they are needed. Such applications have been made possible through special affinities of various agents for different levels. Their structure—and espe¬ cially their content of specific elements which belong to specific levels— account for their tendency to act at specific levels. However, it has often been judged necessary to insure intervention of an agent at a given level by applying it directly at the level itself. The injection of an agent into a tumor or into a region of the body, through surgical chemotherapy, represents one type of procedure insuring level activity. Another procedure has been to inject an agent prepared in vitro so that it is bound to specific body con¬ stituents, such as cells or nuclei. In the latter procedure, the specific defense mechanism is seen to take place at the level of the body constituent and thus desired level activity is obtained.

Digitized by

Google

Original from UNIVERSITY OF MICHIGAN

THERAPEUTIC

APPROACH

/

417

In the development of this research, we faced another problem which is basic to all therapeutic attempts but especially important in cancer: eval¬ uation of the results obtained. Evaluation Incontestably, favorable results have been obtained in cancer with many agents. However, because of the variety of manifestations, evaluation of the changes obtained has been the subject of much controversy. Each clinical worker in cancer has his own ideas about the importance of various changes obtained and often utilizes as criterion changes less accepted by other workers. A systematization of evaluating standards appeared neces¬ sary and it seems possible to do so under the concept of the disease as an organized complex condition. In the minds of most workers in the field of cancer today, any thera¬ peutic procedure aimed at the control of cancer must prove itself in tumors in animals. We have already mentioned the reason why control of human and animal tumors represent two different problems. Failure to recognize that the results obtained in animal cancer do not necessarily apply at all in human cancer has led to failure of the tremendous project of screening virtually all known substances for their effects upon grafted animal tumors. The unguided treatment of cancer in animals, as carried on today, i.e., without any consideration of existing offbalances, seems to explain the limited importance placed upon many changes obtained in these experi¬ ments. But even if evaluation is confined solely to the influence exerted upon the cancerous cells in unguided treatment, the same agent can appear active or inactive, depending mainly on coincidental circumstances. Its in¬ fluence may change from favorable to unfavorable during, and due to, the treatment. Because of this, it is quite probable that many useful agents are not being recognized in the simple screening method used today. Most of the agents which we have found incontestably valuable in guided therapy appeared to be entirely ineffective when used in unguided treatments on small animals. As long as not enough valuable criteria are available to permit guided therapy in experiments in animals, the results would have only a relative value: to furnish useful information about limited problems such as toxicity, special pharmacodynamic activity, etc. Under the concept of cancer as a complex condition, all manifestations, not just those directly related to the anatomical presence of cancerous tumors, must be regarded as important. The tendency of almost all cancer workers is to limit evaluation ex¬ clusively to changes observed in tumors. Without underestimating in any

Digitized by

Google

UNIVERSITY OF MICHIGAN

418

/

RESEARCH

IN

PH YSI O P A T H OLO O Y

way the importance of these changes, we must emphasize the importance of other manifestations. For a subject in the systemic terminal phase, any change obtained in the tumor will have little immediate importance, whereas a beneficial change in systemic metabolic anomalies will be of great im¬ mediate value. Similarly, for a subject in the invasive or painful phase, any influence exerted upon the organic or systemic functions will be of less immediate importance than a beneficial influence upon pain or upon the cancerous lesion. With cancer recognized as a complex condition, the de¬ cision of many scientists, especially clinicians, to limit evaluation to changes only in the tumors would appear to be unilateral and unrealistic. We tried to systematize evalution of results obtained in cancer treat¬ ment by considering all the manifestations present in the patient and by assigning to each its relative value. In addition to any decrease or disap¬ pearance of tumor masses, various analytical changes, improvement in general well-being, gain in weight and control of pain represent accom¬ plishments, the importance of which depends on the severity of these mani¬ festations in the individual case. With all these factors in mind, we have evaluated the various results obtained through biologically guided treatment over a period of many years, relating them to agents and criteria which were changed, of course, as research progressed. The study of different complex conditions has emphasized the fact that many of the manifestations present are common to different diseases. Through the variety of pathological manifestations present in these con¬ ditions, we had the opportunity to study many problems specific for these conditions or of general interest. The therapeutic method consequently has been applied in many noncancerous conditions. Before presenting an analy¬ sis of the progress of this research in the field of cancer, it may be of inter¬ est to review results of the same therapeutic approach in other conditions, each with its specific problems.

THERAPEUTIC APPLICATIONS IN CONDITIONS OTHER THAN CANCER From the beginning of this study, manifestations, clinical and analytical, present in a variety of abnormal conditions, have appeared to conform to the basic physiopathological concepts presented above. In these varied con¬ ditions, however, more often than in advanced cancer, some analyses have shown no abnormal patterns while others have shown them so constantly as to indicate that certain anomalies, often limited to specific levels of or-

Digitized by

G(X >glc

UNIVERSITY OF MICHIGAN

THERAPEUTIC

APPROACH

/

419

ganization, are of great importance. In spite of individual variations, some of the conditions studied have shown patterns and interrelationships of patterns that provide characteristic analytic pictures which will be analyzed in further publications. Furthermore, some of these patterns appear to be so strongly related to a given condition that our attention was directed to the idea of a fundamental relationship between the processes related to the patterns and the pathogenesis of the condition itself. The following ex¬ amples illustrate this. An impressive relationship was found between the presence of peroxides in urine and schizophrenia. We mentioned previously the reaction which we devised for detection of these substances in urine. This reaction would indicate the existence in the body of abnormal processes in oxygen metabo¬ lism, leading to the appearance of peroxides in the urine. We saw that these processes ultimately could be related to an abnormal intervention of fatty acids, corresponding to the oxygen phase of offbalance D. Daily urinary analytical patterns were studied in a group of 27 ad¬ vanced schizophrenics over a period of three years. Over 27,000 urinary samples were examined and more than 135,000 tests performed. Oxidizing substances were found in 87% of these samples. This appears to be highly significant when compared with only 2% positive values in subjects con¬ sidered clinically normal, and 4% in cancerous cases submitted to various treatments. Not a single negative analysis was seen in some of these schizo¬ phrenics during the three years of daily testing. This suggested that the metabolic abnormality, characterized by the appearance of peroxides, might play an important pathogenic role in this disease. (221) Another example of a pattern revealing characteristic pathogenic proc¬ esses was seen in geriatric cases. Old people often have a manifest abnor¬ mality in urinary S. T. Figure 261, page 648 shows the values encountered in old people compared to those in subjects of mixed ages. The high surface tension in the aged group is related to predominance of sterols at the sys¬ temic level. Such predominance is also found at the organic level of the skin, for instance. A clinical test, wheal resorption time, indicated abnormal values for almost all the aged subjects studied, as shown in Figure 68. These data, integrated into the general concept of complex conditions, led us to the pathogenic concept of old age presented above. The urinary chloride retention index in subjects in a state of shock consistently shows such exceptionally high values that our attention was directed to the study of the role of abnormal metabolism of chlorides in the pathogenesis of the condition itself. This view has been confirmed by further research, as mentioned previously.

Google

unnina rrom

UNIVERSITY OF MICHIGAN

420

/

RESEARCH

IN

PHYSIOPATHOLOGY

The study of the different conditions in terms of fundamental patho¬ genic concepts has had other consequences. It has established clearer rela¬ tionships between these conditions and cancer than previously recognized. In fact, many of the data first obtained in the studies of these other condi¬ tions have been applied specifically to cancer. One example is shock. Occurring in the terminal stage and usually leading to death, shock often has been considered to be one of the “com¬ plications” of advanced cancer. Under the concept of organized complex condition, however, it could be seen that, in cancer, shock is related to offbalance type D of the terminal systemic phase. The study of shock has greatly contributed to the knowledge of this offbalance in cancer. The therapeutic approach, in which the choice of agents and the doses used are determined by the different patterns present, has been useful in many noncancerous conditions in which the anomaly apparently is limited to one level of organization or even to a special group of entities. As ex¬ amples here, we will discuss conditions in which manifestations are pro¬ duced by an acid-base tissular abnormality.

ABNORMAL LOCAL ACID-BASE MANIFESTATIONS Pain, itching, vertigo and dyspnea are symptoms of many conditions often far apart etiologically. We have seen that, according to our research, these symptoms are related to an acid-base abnormality at the tissue level. The ideal treatment would be to remove the cause of the symptom, to act upon the etiological factor. This ideal treatment would be entirely different if the symptom stems from a systemic toxic condition, a cancerous lesion, a local inflammatory process or a local allergy, for example. But the great variety of causes that can induce such symptoms as vertigo, pain, itching and dyspnea, often makes this ideal therapy almost impossible, particu¬ larly in everyday medical practice. Another approach to controlling these symptoms would be one which is not especially concerned with the etiological factors involved but with influencing the specific pathogenic changes underlying each of these symp¬ toms. But as such specific changes have not yet been defined, symptomatic treatment has remained as the only practical recourse in these instances. Recognition in the physiopathological changes present in pain, itching, vertigo and dyspnea of an acid-base pattern, has permitted another thera¬ peutic approach on a different, more precise basis. These symptoms, with their dual pathogenesis, have been treated according to the two possibili¬ ties: acid or alkaline pattern. Identification of the specific pattern, as noted

Digitized by

Google

Original from UNIVERSITY OF MICHIGAN

THERAPEUTIC

APPROACH

/

421

previously, is simple. Furthermore, pain results from an abnormality present at one level of organization, the tissues. With two groups of antagonistic agents, both capable of acting at the tissular level, the therapeutic problem is reduced to the choice between these agents according to the pattern present. The therapeutic problem—previously so complex because of the need to consider so many possible etiological factors so often unrecog¬ nizable—is simplified by this approach to a choice between two groups of agents, determined by one easily identifiable factor. The means used to recognize the acid-base pattern vary with each symptom. We present here a resume of the research made in this direction. Pain We have seen that pain can be sensorial or symptomatic, and that the latter has a dual pathogenesis with an acid or alkaline pattern. Reduced to the problem of an acid or alkaline offbalance occurring at the tissular level, the treatment of pain is greatly simplified. The first problem was to determine the pattern present. The relation¬ ship between variations in the curve of pain intensity and concomitant changes in the urinary pH, previously discussed, has been used for such determinations. The simplified method of comparing two urine samples, one corresponding to a period of pain and the other to one of calm, has proven very useful. Among other analyses, only changes in serum potassium content have appeared helpful in the recognition of the pain pattern. This can be ex¬ plained by the fact that most of the other routine analyses do not inform us specifically about changes at the tissue level where pain occurs. A high serum potassium level, increasing during pain exacerbation, indicates an alkaline pattern; a low level, decreasing during pain exacerbation, indi¬ cates an acid pattern. Another, sometimes simpler, technique for recognizing the pattern is the response of pain to administration of acidifying or alkalizing agents, as seen above. Also, some substances, while being used as therapeutic agents, indicate the pattern through the responses they induce. Butanol and sodium thiosulfate in adequate dosages (1 cc. of a 6.5% solution of butanol or 1 cc. of a 4% solution of sodium thiosulfate injected intramuscularly) are examples. The intensity of an acid pattern of pain is increased by butanol, and decreased by thiosulfate. The inverse occurs in pain of an alkaline pattern. With the pattern of the pain recognized through one of these means, agents are chosen from the two groups, anti-A for acid pattern and anti-D for alkaline. In each group however, some agents have been found to be

Digitized

Google

Original from

UNIVERSITY OF MICHIGAN

422

/

RESEARCH

IN

PHYSIOPATHOLOOY

more effective than others because of their greater activity at the tissue level. The following agents have been found to be most effective against acid pain, in the order presented: lipoaldehydes and especially propionic alde¬ hyde, sodium thiosulfate, sulfurized tetrahydronaphthalene, the acid lipid fraction of various organs, polyunsaturated fatty acids, epichlorohydrin, and selenium in the form of perselenide. For an alkaline pattern, agents with a positive polar group, such as butanol, nikethamide, insaponifiable fractions, glycerol and heptanol are effective in that order. Once the agent to be used is chosen, the dose which can vary greatly from case to case, is easily determined from the clinical response. In prac¬ tice, the patient is given a small dose. If the intensity of the symptom de¬ creases but is not completely controlled, the same dose is usually given three hours later. If the symptom intensity remains the same, the dose is continuously increased more or less rapidly, in accordance with the severity of the symptoms, the medication being repeated this time at intervals vary¬ ing from a half hour to every three hours. On the other hand, if the symptom disappears after the first adminis¬ tration of the agent, medication is not repeated until the symptom reappears. If the symptom is controlled for less than six hours by the dose used, the same dose is given when the pain reappears. If more than six hours of relief follow a dose, the next dose is usually reduced in proportion to the period of time the effect lasted. If 24-hour relief occurred, the dose is reduced by half; if relief was of two days’ duration, one-quarter of the last dose is given. However, if, with three successive doses of medication, the symptom increases in intensity each time, always during the first half hour after the medication is administered, it is discontinued and the entire group of agents to be used is reconsidered. A new test for the pattern is performed. If the pattern is the same as before, other agents from the same group are tried. However, if the pattern now is opposite to the original pattern, the group of substances has to be changed. This technique has produced, with few exceptions, excellent pain relief. This approach to pain has been the object of several controlled studies. S. A. Barragan Martinez (183) and E. Stoopen, (184) in the journal “Pasteur,” confirmed our conclusions. From Stoopen’s publication we quote two characteristic observations in Note 1. An intensive study of head and neck pain was made by B. Welt and published in the American Medical Assn. Journal of Laryngology (185). with the following conclusions:

Digitized by

Google

UNIVERSITY OF MICHIGAN

THERAPEUTIC

APPROACH

/

423

"Summary and Conclusions A series of 120 patients having the symptom of pain in the region of the head and neck has been studied. The symptom of pain has been analyzed according to Revici’s concept concerning the alkaline or acid pattern of the painful symptom. Eleven cases were eliminated because no pattern was identified; 109 cases showed an acid or alkaline pattern. The results showed a satisfactory result in 84% of the vascular headaches, 100% in migraine headaches, and 75% in the neuralgic group. These results indicate a correlation of Revici’s concepts and the results achieved. The simplicity of this method is indicated. Additional data about Revici’s views are given. The relationship to homeostasis and the biology of the cell is indicated. The problem confronting the clinician in treating cases of this type, on account of the many factors involved, is simplified according to Revici’s concept of dualism. Two additional active products are presented, one acid and the other alcoholic. The data here presented concerned the incidence of the control of the acute symptoms while under observation. Further experience with this method will be necessary. As the method stands, it is a practical method of therapy for the control of pain. Recurrences were seen and controlled.” Our method of controlling pain was the subject of a panel discussion at the American Academy of Ophthalmology and Otolaryngology, New York, N. Y., September 21 and 22, 1954, and of an article published by B. Welt and M. Welt in Modern Problems of Ophthalmology. (186) (Note 2)

Trauma A particularly interesting application of the method described above is in the treatment of pain related to traumatic lesions. The study of wounds from the standpoint of the offbalance present has revealed a definite pat¬ tern in their evolution. In all wounds, there is an initial period during which the offbalance is always type D, corresponding to a predominance of fatty acids. This can be recognized indirectly by measuring the local pH which shows alkalosis, the chloride content which shows a manifest in¬ crease, and by cytological and histological studies which indicate a rapid cellular aging process, with necrosis and sloughing. In uncomplicated wounds, in humans, the painful period usually lasts a few days. The pain in this initial period is of an alkaline pattern. The constancy of the alkaline pattern in pain in traumatic lesions elimi-

Digitized b

Google

Original from UNIVERSITY OF MICHIGAN

424

/

RESEARCH

IN

PH YSIOP ATHOLOOY

nates need for any tests, thus simplifying therapeutic choice by reducing agents to be used to one group—those with positive character. As already noted, some of the agents are more effective than others in influencing alkaline pain. Butanol and heptanol are particularly useful in traumatic pain, followed in order of activity by polyunsaturated alcohols, nikethamide and glycerol. One important application of these findings is in routine treatment of postoperative pain. For surgical wounds, which represent typical traumatic lesions, butanol appears to be especially beneficial. Its use has been the subject of extensive studies by B. Welt (187) in surgery in otorhinolaryn-

0 - little or no pain + • pain Fig. 144. Results obtained with butanol in postoperative pain—compared with sub¬ jects receiving saline as placebo—(From B. Welt—AMA Archives of Otolaryngology. $2.540,1950.)

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

THERAPEUTIC

APPROACH

/

425

0 * minimal or no pain + • moderate or severe pain Fig. 145. Results 12 hours after the butanol injections. (From B. Welt, AMA Ar¬ chives of Otolaryngology, 50, 590, 1950.)

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

426

/

RESEARCH

IN

PH Y SI OP A T H OLO O Y

gology, (Note 2) (Fig. 144) by M. Welt in ophthalmology (188), by A. Ravich in urology (189) (Note 3), and by S. Sheer in plastic surgery. (190) With more than 10,000 cases treated, butanol seems to be completely safe as well as highly effective. Not a single case of undesirable reaction due to the medication has been noted. The dose necessary to obtain pain relief varies with the amount of traumatized tissue. With an adequate dose of butanol, the patient has a minimum of pain, is conscious, and without impairment of intestinal and bladder function. Butanol also has a marked preventive action against hemorrhage, which will be discussed below. Success with this medication depends upon adequate dosage. The ad¬ dition of butanol to the saline solutions customarily used in postoperative care has done much to simplify the problem of administering it in adequate doses without resorting to supplementary injections. Doses as high as 100 cc. or even 200 cc. of 6.5% solution of butanol have been administered in the first days following surgery, with good results and no inconvenience to the patient. Administered by injection or orally in only very small doses, heptanol is helpful. A mixture of heptanol, butanol and polyunsaturated alcohols constitutes a valuable preparation for controlling postoperative pain. Butanol, heptanol and glycerophosphoric acid added to glucose and saline has proved very helpful to control not only pain but also the other disagree¬ able post-operative manifestations. (Note 4) In other forms of trauma, such as accidental wounds or fractures, the same agents have been equally successful if in sufficient doses. With their use, the healing period seemed to be shortened, as shown in experiments in rats and rabbits. In animals with standardized wounds, the healing of connective tissue in particular is accelerated. In wounds treated with preparations of cholesterol, sterols or insaponifiable fractions of or¬ gans, the healed epithelium shows abnormally high proliferation.

Bums The pain of bums has been successfully treated with higher alcohols such as butanol, heptanol or polyunsaturated alcohols. However, here the prob¬ lem is not so simple since pain is only one, and not the most important, of the manifestations. Systemic functions are often so greatly impaired as to represent the immediate cause of death. The higher alcohols are effective in controlling pain and local troubles, while other agents are needed when the condition also involves the systemic level. Glycerol and especially sterols which are present in the insaponifiable fractions of organs such as

Digitized by GOOglC

UNIVERSITY OF MICHIGAN

THERAPEUTIC

APPROACH

/

427

placenta, are very helpful in these cases. Anuria of several days’ duration has been influenced in several cases, with abundant diuresis occurring only a few hours after the administration of 2-4 cc. of a 10% solution of the insaponifiable fraction of placenta, an effect not obtained with butanol alone, even in large doses. The effect was still more impressive when large doses of butanol, such as 10 cc. of the 6.5% solution every hour, were administered for a few hours before injection of the insaponifiable fraction. The addition of sodium lactate to butanol in sufficient amount has been seen to favorably influence systemic problems related to bums. Experi¬ mentally, we have shown the value of this preparation in extending the survival time of mice. Under ether anesthesia, adult mice were scalded in water at 90°C for three seconds up to the xyphoid appendix. The survival period for un¬ treated animals was short. Of the various preparations used, the buta¬ nol-sodium lactate mixture seemed to be the most active in prolonging survival. (See Note 13, Chapter 10 and Fig. 138) Ultraviolet ray burns, such as occur in sunburn, have been treated with butanol in several hundred cases. We started with 5 cc. of the 6.5% solu¬ tion orally, and repeated the dose every 10-15 minutes until the painful sensation disappeared. When the burning sensation reappeared, treat¬ ment was resumed. It could be seen that butanol not only controlled pain rapidly and completely but also that the skin lesions healed in a shorter time than in untreated subjects. X-ray and radium bums in animals and humans have responded to the same substances as mentioned above. Standardized ulcerated radiation lesions were inflicted in rats by inserting, between the lips of a skin in¬ cision, a needle with radium in platinum or monel metal. A needle with 25 mg. radium in monel metal was kept in place for two hours, one with 10 mg. in platinum for 96 hours. Ulcerations resulted and took four weeks or more to heal. In animals treated with sterol preparations, such as in¬ saponifiable fractions of placenta, wounds healed in much shorter time. Similar effects could be obtained with butanol, although less consistently. Good results were obtained with the same treatment in radiation bums in humans. In relatively new lesions, pain was relieved after a day or two and rapid healing usually followed. Even in old bums which had not healed for many years, pain was controlled in less than a week and the lesions started to heal. In some of these, scars developed in less than a month.

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

428

/

RESEARCH

IN

PHYSIOPATHOLOGY

Vertigo Another interesting application of the same therapeutic method has been in otological conditions. B. Welt has made a stimulating contribution to the study of ear conditions in terms of the pathogenic mechanism in¬ volved and an even more valuable contribution to therapy. Vertigo was one of the conditions studied. In a few cases, by comparing concomitant variations in the intensity of the symptom and changes in the urinary pH, we had been able to show that acid and alkaline pathogenic patterns exist, similar to those seen in pain. Going on from there, B. Welt, in an extensive study, has shown the presence of this dualism and has successfully applied the therapeutic method discussed above, to a significant number of cases of vertigo. The major advantage of this method over other treatments for this condition lies in its extreme simplicity. For vertigo, which has so many different causes, an etiological approach although ideal, has seemed impossible to all workers in the field especially as a routine procedure in medical practice. An initial simplification of the approach could be made by relating vertigo to acid and alkaline patterns, thus reducing treatment choice to two groups of agents. Welt, in a further step, simplified even this procedure, making the method highly applicable in routine medical practice. He administered to patients one or the other of two agents chosen from each group, such as butanol or sodium thio¬ sulfate, being guided in his choice by clinical aspects such as changes in the symptom with the time of day or the intake of food. A favorable change in the symptom was considered to be a confirmation of this tentative diag¬ nosis of the pattern. The treatment was then continued with the same group of agents. An increase in vertigo led to the use of the opposite group of agents. The clinical results obtained by Welt with this simple method are impressive. (190) He arrives at the following conclusions: “Summary and Conclusions A series of 44 patients having the symptom of dizziness has been studied. The symptom of dizziness has been analyzed according to Revici’s concept concerning the alkaline or acid pattern of the symptoms. In 80% of the analyzed cases, the responses have shown the existence of an alkaline or an acid pattern; 12% showed an inconsistent relationship; 8% showed no result.

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

THERAPEUTIC

APPROACH

/

429

A therapeutic approach has been devised which corresponds to the presented results. The control of the symptom of dizziness by this therapeutic approach has been obtained in 80% of the cases. As compared with other methods of treatment, which are prolonged and involved, Revici’s approach is simple in application and effective in its results. This therapeutic approach based on the dualistic pattern of the physiopathology of the pathological tissues is especially applicable to the symp¬ tom of vertigo, which because of the multiplicity of the etiologic and pathogenic factors make a direct medical attack almost impossible. The evidence presented in this communication relates to the control of the acute attacks of vertigo. Recurrences were observed in this series and successfully controlled. In the cases submitted in this communication and in subsequent cases subjected to this form of therapy, further observation by this method will indicate whether or not the lesion is permanently controlled.” Welt completed his vertigo study by using many other members of the same groups of agents as they were studied by us for other conditions. The following conclusions appear in Welt’s second publication on vertigo. (191) “Summary and Conclusions A series of 106 cases with the symptom of vertigo has been presented in this and a previous paper and analyzed according to Revici’s concept of a metabolic imbalance which exists in pathological foci and manifests itself as a local alkalosis or acidosis. Seven cases were eliminated for lack of data. This left a total of 99 case studies. This figure represents the sum of 42 cases termed the 1953 series and the present series of 57 cases. The two series were combined and analyzed according to sex, alkaline or acid character of the symptom, and clinical diagnosis. The analysis showed an average good result of 80% for both series. This percentage indicates a consistent correlation of the use of Revici’s method and substances with the results achieved. Additional substances from various sources were utilized in the present study. It is here again emphasized that I have submitted this article for the practical reason that the method described is simple and has been successful in its application. In addition, it gives a new systematization to clinical data in the field of otolaryngology. Finally, this communication points to a vast group of sub-

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

430

/

RESEARCH

IN

PHYSIOPATHOLOOY

stances from widely differing sources and of different structures which have similar biochemical activities. The substances presented here are but a few, but they open a pathway for the development of other substances having similar biochemical activities. It is to be hoped that these too, may have a practical application in the field of otolaryngology. Views on cell permeability and their relationship to fatty acids and sterols are added. The role of foci of infection and psychological aspects in their relation¬ ship to the symptom of vertigo is amplified. The simplicity of this method of therapy is emphasized, and its inte¬ gration with a new method of systematization of clinical knowledge is indicated.” Hearing Impairment Deafness remains the most important problem in otology despite good results recently obtained with surgical procedures such as fenestration and stapes mobilization. Since deafness results from long evolving processes, a logical approach to the problem would be not to wait for the advanced stage where surgery must be used but to try to control the processes before they reach this ultimate state which usually corresponds to sclerosis. Studies of the morphological changes related to progressive deafness have been too limited to present a basis for a biological or biochemical therapeutic ap¬ proach that would have a chance of success. The nature of the lesions, their minuscule dimensions, and their chronic evolution, offer no oppor¬ tunity for direct information. Consequently, we tried to adapt to this situ¬ ation the knowledge acquired through research in the field of abnormal processes in general. Just as for pain, it was observed that some patients with hearing im¬ pairment are aware of differences in their acoustic acuity according to the time of day, i.e. some hear better in the morning, some in the evening. There seemed also to be a correlation with the intake of food. Based on these observations, cases of various degrees of surdity were investigated for relationship to acid-base changes. Some subjects showed audiometric variations under the influence of acidifying or alkalizing agents, while others did not respond. When two antagonistic agents were used in the same sub¬ ject and hearing acuity was analyzed, the changes occurred in two opposite directions. We could interpret this only by analogy to changes in pain and other acid-base symptoms. Accordingly, we postulated that in some cases no activity is going on in the lesions since no changes are induced in the

Digitized by

Google

original rrom

UNIVERSITY OF MICHIGAN

THERAPEUTIC

APPROACH

/

431

audiogram by administration of acidifying or alkalizing agents; in others, there is activity which is acid or alkaline in pattern. Thus, the existence of a response was considered to indicate a still active lesion. Time is not the determining factor. Even in relatively recent lesions, biological activity may have ceased while in other cases, even with very advanced hearing impairment, lesions can still be evolving, with proc¬ esses not yet advanced to the sclerotic scar phase. This aspect has been extensively studied because of the therapeutic implications, since only an evolving state could possibly be influenced by this method of therapy. The influence of agents used in other conditions with acid-base patho¬ genesis was studied in cases of impaired hearing. The first attempt made years ago, with fatty acids and sterol preparations, was not successful. Much better results have been obtained with more recently developed syn¬ thetic agents. In the last five years, Welt has devoted much time and effort to this research. He has made thousands of complete audiograms and has used a series of active agents with placebos for control. (192) Welt has studied approximately 460 cases to date. (Note 5) In the simplified form, an agent from one or the other group was used for a short time and im¬ provement in the audiogram was taken to indicate that a suspected pattern, acid or alkaline, was actually present. Clinical results have largely confirmed theoretical views. Regardless of degree of impairment, improvement ranged from nil or almost nil in cases with no more signs of activity, to good and excellent in those with still active lesions. In young patients in whom the proportion of active lesions is high, results were particularly impressive. Hearing impairments of 60-70 decibels or more have been overcome, sometimes in only a few weeks of treatment. These results have been observed to persist in many cases, some thus far for more than three years. However, a tendency for impairments to recur, usually following rhino-pharyngeal infections, has been noted. Generally, renewed treatment has been able to restore hearing to previous values in a short time. (Figs. 146 to 150) It appears superfluous to emphasize here the importance of this con¬ tribution to the medical and social problem of deafness. It represents the first approach to treat successfully the pathological processes related to impaired hearing before they lead to advanced lesions which can no longer be influenced except by surgery. Every case of incipient or even advanced hearing loss should be investigated by the simple technique devised by Welt to see if correction by this method is still possible. Surgical intervention should be reserved principally for patients with lesions which correspond to sequels and who no longer respond to biochemical treatment. But even

zed by

Google

unoinfli rrom UNIVERSITY OF MICHIGAN

432

/

RESEARCH

IN

PHYSIOPATHOLOGY

Left Ear - L.L.

Initial After treatment

Fig. 146. Manifest improvement in the impaired hearing is obtained in a subject with acid pattern, through guided treatment with negative lipoids. (Courtesy of Dr. B. Welt.)

Right Ear - L.L

Fio. 146bis. In the same patient as in Fig. 146 the improvement is not as manifest for the right ear as for the left ear.

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

THERAPEUTIC

APPROACH

/

433

AUDIOGRAM - Right Ear - F.M M 7Jf 1M 1JM HM Ml 4M NN tM

Final Initial

Fig. 147. Only a relative improvement is obtained in a case with alkaline pattern of impaired hearing.

AUDIOGRAM - Left Ear - F.M )» 1M ISM 2M UN 400C (IN IM

Nraal •

Final

5

»

Initial

I rjrf.fA

Fig. 148. A still smaller result is obtained in this case for the left ear.

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

434

/

RESEARCH

IN

P H Y SI O P A T H O L O O Y

AUDIOGRAM - Left Ear - A.W

mmmimmmmmm

r-

na

Fio. 149. An exceptionally good result is obtained for the left ear in the case A.W. in spite of an initially very impaired hearing.

AUDIOGRAM

-

Right Ear - AJrf

y 7M 1W11501 2109 1911 4111 99>9 9999

Final

Nml 9

Fio. 150. Manifest improvements are obtained in this case with alkaline pattern of impaired hearing.

Digitized b

Google

Original from

UNIVERSITY OF MICHIGAN

THERAPEUTIC

APPROACH

/

435

surgical cases can benefit from biochemical treatment which could prevent further sclerosis which often follows surgery. Application of this method in time to prevent deafness would be even more important than restoring hearing in far advanced cases.

Itching Acid and alkaline patterns of itching have been recognized, and treatment based upon dual pathogenesis has been applied. The agent to be used is determined by the pattern found through analyses. Dosage, as for pain, is established according to the subjective response. Following these methods, many cases of intractable itching have been completely controlled. Of the group of agents with positive character, butanol and heptanol have pro¬ duced the best results; in the opposite group, epichlorohydrin and sodium thiosulfate have been most effective.

Gallbladder and Renal Colic Attempts were made to influence renal and gallbladder colic by using the same method. Butanol has shown little effect upon renal colic at least in the doses we tried. But the results in gallbladder colic were impressive. A 6.5% solution of butanol in saline injected intramuscularly, or even 15-30 cc. (one or two tablespoonsful) of 6.5% solution of butanol in water ad¬ ministered orally when the patient was not vomiting, controlled gallbladder colic rapidly. Only twice in more than 20 cases in which butanol was used was it necessary to give larger doses, such as 50 cc. of the same solution, to obtain the desired effect.

Arthritis The analysis of the pattern of pain has shown that often in rheumatoid arthritis the pattern is alkaline, while in osteoarthritis, it is acid. Compari¬ son of variations in pain intensity with changes in urinary surface tension helps to determine the pattern. However, with urinary surface tension values used as a guide both for agent and dosage, favorable clinical results have been obtained in cases resistant to other therapy. Arthritis, painful for many months, was controlled in many instances with several doses of heptanol or of sodium thiosulfate with epichlorohydrin and more recently with propionic aldehyde or sulfurized tetralin. The simplicity of treatment, total lack of undesirable side effects, and the long period of improvement

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

436

/

RESEARCH

IN

PHYSIOPATHOLOOY

after even brief treatment in some cases, indicates that this method is worthy of further investigation. Some illustrations of the results are con¬ tained in the following observations: Case #7 Mr. M. R., 63 years old with a long history of arthritic pains. Four years ago he was obliged to stay in bed for three months for severe pains in the right sacroiliac region. Two years ago he was again bedridden for a month and a half because of the same type of pain. A year ago, pain started again in the same sacroiliac region, to be followed by a very severe sciatica which kept him in bed for two months. Repeated X-ray examina¬ tions showed advanced arthritic lesions in the lumbar spine and around the sacroiliac articulation. About ten months ago, he suffered another similar attack, with severe pain, in the same region. Urine analysis made at this time showed an offbalance of the type D with low surface tension, low pH and high specific gravity. The blood serum potassium was high (5.3 mEq.). The patient was treated with agents of the group D—1 mg. of heptanol and 30 mg. butanol three times a day. The patient remained free of symp¬ toms for four months, when similar severe pains were again present. This time analysis showed an offbalance of type A, with high urinary surface tension, high pH, low specific gravity and low blood serum potassium (4.0 mEq.). For this reason, different medication of the group A—5 mg. epichlorohydrin and 50 mg. sodium thiosulfate—were administered. The re¬ sponse was as rapid as previously and pain disappeared within a few hours. Since then the patient has been taking 5 mg. epichlorohydrin and 50 mg. sodium thiosulfate twice a day whenever the slightest pain appears. The clinical results are excellent, the patient being now able to move about entirely free of pain, as he has not been able to do for many years. Core #2 Mrs. F. R., 60 years old, was bedridden for one and a half years about six years ago, with lumbar and sacroiliac arthritic pains. X-ray treatments, short wave, ionization with histamine and ultrasonic treatments appeared entirely ineffective. The administration of urolytic agents had helped at this time. The pains recurred repeatedly in the last three years keeping the pa¬ tient in bed for from one week to three months at a time. For the past eight months, the patient has been under treatment using medication of the group A or D, according to the urine analysis. With this treatment the pain has been completely and rapidly controlled, never lasting more than a few hours.

Digitized b

Google

Original rrom

UNIVERSITY OF MICHIGAN

THERAPEUTIC

APPROACH

/

437

Case #3 Mr. N. K., 55 years old, suffered for many years with generalized and very painful rheumatoid arthritis. Prior to coming under our care, he had been bedridden for six months, entirely immobilized with severe pain in arms, back and legs. The patient was entirely incapacitated, unable even to feed himself. Treatments with different cortisone preparations, ACTH, gold, etc., provided practically no relief of the severe pains. He came under our care, entirely immobilized and in severe pain. According to the anal¬ ysis which showed a low urinary specific gravity, and pH, high surface ten¬ sion and a low blood serum potassium, the patient received medications of the group A, sodium thiosulfate, epichlorohydrin and heptyldiselenide. Un¬ der this medication the patient made a most dramatic recovery. Within a few days, the patient was out of bed without pain, walking normally and with full functional capacity of his arms and legs. While still under treatment the patient went back to entirely normal activity. He gained 35 lbs. in the last months.

Connective Tissue Conditions We have discussed previously the hypothesis that corticoids actively in¬ tervene in the synthesis of an entire group of substances in the organism. The energetic formation between Cu and C21 of these corticoids would act as a mold or template to attract and keep various radicals in special recip¬ rocal position, thus favoring, as a second step, the synthesis of new sub¬ stances. These substances would vary according to the energetic formation of the corticoid. In one group, which could be called the “gluco” group, we identified glucose, glucuronic acid, glucosamine, galactosamine, glucosaminic acid, galactosaminic acid, and some other uronic acids. Even ascorbic acid could be related to such a synthesis mechanism. We investigated some of these substances, particularly in relation to the therapeutic properties of corticoids. In 1951, we chose glucosamine as a substance closely corresponding to the template of cortisone. Glucosamine treatment was used in patients with pemphigus, rheumatoid arthritis, psori¬ asis, ocular condition and allergy. The following cases illustrate the results obtained. Mr. H. S., 46 years old, had generalized psoriasis. In the last twelve years, the lesions had progressed continuously to cover more than 75% of his skin. Local treatment had had little effect. Cortisone injections cleared the skin in two weeks but not completely. With

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

438

/

RESEARCH

IN

PHYSIOPATHOLOOY

cessation of treatment, the condition returned. The patient remained without treatment for a few months before beginning our treatment: 5 cc. injections of glucosamine 10% solution administered daily. Changes were seen in 3 days, with the lesions becoming paler and less scabby. With two injections daily, the skin was almost entirely normal in about 10 days, only a few lesions remaining. Continuation of the treatment for another week did not make these disappear. Upon cessa¬ tion of treatment, the lesions regressed to their previous dimensions. In a second course of treatment, with two daily injections of 5 cc. of a 10% solution of glucosamine in saline, the lesions cleared but re¬ appeared when treatment was discontinued. We also treated a series of cases of rheumatoid arthritis and found that subjects, who had previously responded well to cortisone, also re¬ sponded to glucosamine. Mrs. B. B. had rheumatoid arthritis of the left knee and both hands. Pain and swelling were severe. The patient had responded fairly well to cortisone, but due to retention of water, this treatment was discontinued. In less than 10 days, the arthritis returned. The patient was given glucosamine injections. At first, 5 cc. of the 10% solution in saline was injected once a day. Later, 3 injections daily were used. The symptoms, which had decreased with the lower doses, were fully controlled by the 3 daily injections. Pain and swelling fully disappeared. Moon face was not observed. The treatment was con¬ tinued with 2 injections daily and, after one week, one injection daily. With this dose, pain and swelling returned. Resumption of 3 injections a day controlled them again. The treatment was discontinued because of the apprehension of the patient over receiving 3 injections daily of 5 cc. each. A mixed treatment with a lower dose of cortisone and one injection of glucosamine daily was continued with satisfactory results for a few weeks, after which the patient stopped her visits. We treated cases of rheumatoid arthritis with oral glucosamine with fair to good results. Four grams of glucosamine a day appeared to be the minimum requirement. Good results could be seen in some cases after doses of 5 to 10 grams daily. These results were confirmed by B. Welt who, fol¬ lowing his research, used the same preparation of glucosamine on a series of 15 patients bedridden with arthritis at the Greenpoint Hospital in Brook¬ lyn, New York. Subjective and objective improvement occurred in patients with rheumatoid arthritis while no changes were seen for those with osteo¬ arthritis. For more than one year, Welt has treated a case of pemphigus with injections of glucosamine and has been able to prevent the appearance of new lesions.

Diq

Google

UNIVERSITY OF MICHIGAN

THERAPEUTIC

APPROACH

/

439

In a few cases of iridocyclitis, treatment with glucosamine (2 injections of 5 cc. of the 10% solution daily) healed the lesions in two or three days. Galactosamine produced results almost similar to those of glucosamine. Still better results were seen with glucosaminic acid, used in the same doses as glucosamine. Some strikingly good results in several cases of arthritis were obtained with gluconic acid administered orally in doses of a few grams a day (four tablespoons of a 25% solution).

Hemorrhage In studying hemorrhage, it seemed necessary first to define precisely the conditions under which this important episode occurs, as we did for pain, itching, etc., since the course of hemorrhage, and particularly its response to treatment, seems to depend greatly upon certain peculiarities related to its pathogenesis. Hemorrhage results from a break in the continuity of a blood vessel, which can be induced by an external influence on a previously normal vessel, or can occur as a result of processes taking place in abnor¬ mal vessels. We have called the first type of hemorrhage “accidental” or “traumatic” and reserved the term “pathological” for the second, which appears to be a direct result of pathological changes in a vessel. The latter term is used in the same sense as it is used for fractures where “pathologi¬ cal” indicates only preexisting lesions in the bones. In a traumatic hemorrhage, the therapeutic problem is limited to stop¬ ping the flow of blood. Mechanical means to close the bleeding vascular wound or agents able to increase the capacity of the blood to form clots can be used. They represent the only approach in accidental hemorrhage. In pathological hemorrhage, other problems arise. The knowledge of the local pathological changes, which lead to the appearance of bleeding, is important both for preventing and controlling hemorrhage. The patho¬ genic factor involved will be considered along with the problem of hemo¬ stasis. Hemorrhagiparous Agents Local and general factors are involved in pathological hemorrhage. Ul¬ cerated lesions provide a favorable condition. So does local infection. Anti¬ coagulants may act indirectly upon blood vessels. Hemorrhagiparous properties of some substances became evident dur¬ ing research on their therapeutic use in cancer patients. For example: P. T., a patient with carcinoma of the floor of the mouth widely ulcerated in the submaxillar region, bled sporadically from the lesion.

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

440

/

RESEARCH

IN

P H Y S I O P A T H OL O G Y

When a dose of 20 drops of Coramine (brand of nikethamide) was given for his general condition, a relatively severe hemorrhage ap¬ peared immediately afterward. There was another hemorrhage when a similar dose was administered 12 hours later. Suspecting a correla¬ tion between hemorrhage and medication, medication was discon¬ tinued and there was no hemorrhage during the following two weeks. When only 10 drops of Coramine solution was given again, a new hemorrhage appeared. After two more weeks without Coramine and without hemorrhage, a new dose was given to check the correlation between medication and bleeding, and was followed again by hemor¬ rhage. Reviewing cases lost through hemorrhage, we could find several in which lethal bleeding was preceded by administration of Coramine in the usual dose. This hemorrhagiparous effect was noted so consistently as to make us discontinue use of Coramine in cases with ulcerated lesions. Alerted by this experience, we noted hemorrhagiparous activity in other agents. Glycerol, we found, could induce severe bleeding even when administered in doses as low as 5-10 drops, and two lethal hemorrhages were traced to such doses. Thiamine chloride in therapeutic doses—such as 100 mg. injections—produced hemorrhages. A similar hemorrhagiparous effect was noted for isamine blue. Glucose, administered intravenously in large doses to patients with ulcerated and infected cancerous lesions who had previously hemorrhaged, induced new bleeding. We must emphasize that all the hemorrhagiparous agents produced the bleeding effect, espe¬ cially in subjects who had previously had hemorrhages from their lesions. This would indicate the importance of local changes. In such patients, other agents also induced bleeding. In some cases of gastro-intestinal can¬ cer, bleeding followed a normal dose of aspirin. But even in lesions which had never bled, the first group of hemorrhagiparous agents—Coramine, glycerol and thiamine—could induce bleeding. In trying to correlate the pathogenesis of these hemorrhagiparous ef¬ fects with existing offbalances, an interesting relationship was noted. A tendency to bleed was found to be promoted by sterols. Administration of cholesterol in doses as high as 5 cc. of a 2% solution in oil, two or three times a day, for several days, was followed by hemorrhage in patients with ulcerated lesions. This occurred only in a few cases. But a high sensitivity to other hemorrhagiparous agents often developed. The administration of minimal doses of glycerol produced bleeding in subjects treated with cho¬ lesterol and did so even more frequently when large amounts of insaponifiable fraction of organs were administered.

Google

UNIVERSITY OF MICHIGAN

THERAPEUTIC

APPROACH

/

441

Hemorrhages which follow administration of these hemorrhagiparous agents are usually severe and of arterial character. Examination of such bleeding lesions has revealed transverse severance of small or even medium arteries. Only rarely was there oozing bleeding from capillaries or small veins. In several cases, administration of hemorrhagiparous substances in¬ duced petechiae or purpura, but this occurred only when thrombopenia was also present. The petechiae were seen at sites where local circulatory impairment already was present. We believe that this hemorrhagiparous effect must be emphasized for its clinical importance. Products such as Coramine (nikethamide) and thiamine are widely used as therapeutic agents and glycerol is a common vehicle for pharmaceutical preparations. There¬ fore, we must bear in mind their possible role in hemorrhages. In subjects with ulcerated lesions, their administration has to be banned or special precautions must be used. The same precautions have to be taken for the use of glucose in cases in which a previous hemorrhage has not been con¬ trolled by mechanical means.

Antihemorrhagic Agents Butanol In activity

1943, during research studies concerning the of

glycerol

on

abnormal

foci,

its

pharmacological

hemorrhagiparous

effect

appeared as a serious handicap. Various hemostyptic substances were tested without sufficient effect. At this time, a new product, to which a hemostatic effect was attributed, appeared on the market. It was a very weak solution (around 1/10,000) of octanol in saline. We could find no therapeutic effect for it. However, we were studying butanol and other higher aliphatic alcohols with lipoidic properties, and we decided to test butanol for its antihemorrhagic activity, hoping that it might counteract the undesirable hemorrhagiparous effect of glycerol. It did and we have since added butanol to glycerol for this purpose. We observed the remarkable hemostatic effect of butanol years later in a patient with severe hemorrhage, to whom doses of 10 cc. of a 6.5% solution were given intravenously. Hemorrhage stopped in a few minutes. Since then, we have successfully applied butanol clinically in hemorrhages of various origins. As an antihemorrhagic agent, butanol is administered either parenterally as a 6.5% solution in saline, or orally as 6.5% solution in water. The route of administration—intravenous, intramuscular, subcutaneous or oral

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

442

/

RESEARCH

IN

PHYSIOPATHOLOOY

—is chosen according to the severity of the hemorrhage. Doses of 5-20 cc. are given and repeated, if necessary, at intervals of a few minutes. Since butanol is not at all toxic in these large doses, we usually give them with good results in severe emergencies. The following cases illustrate the styptic effect. R. E., a 64-year-old man with an extensive ulcerated epidermoid carcinoma of the floor of the mouth and large bilateral cervical metastases, had received intensive radiotherapy. Occasionally, there was a small amount of bleeding from the oral lesion, but a sudden hemor¬ rhage of about 500 cc. of blood during a half hour period occurred late at night while the patient was at home. Pressure, applied to the floor of the mouth, was of value but bleeding recurred immediately upon release. Oxidized gauze, adrenalin soaked gauze, vitamin K and vitamin C in large quantities were of no value. n-Butanol solution in saline was finally obtained and 5 cc. injected intravenously. Bleeding ceased during the injection. A second equally severe hemorrhage oc¬ curred one week later and again could not be adequately controlled by pressure or oxidized gauze. 10 cc. of n-butanol solution admin¬ istered intramuscularly stopped the bleeding within 2-3 minutes. Three hours later, the floor of the mouth was carefully examined prelimi¬ nary to right external carotid artery ligation, and the lesion was found to be free of bleeding. Despite the ligation, bleeding later recurred but was controlled each time by n-butanol administered orally. S. S., a 30-year-old man, had an adenocarcinoma involving the right maxillary sinus with cervical metastases. During the period of observation, this patient experienced a profuse hemorrhage from nose and mouth. Blood flowed at the rate of approximately 5-6 cc. per minute, and pressure gave little or no relief. 5 cc. of n-butanol in saline solution was injected intravenously and within two minutes, the profuse hemorrhage ceased and did not recur at that time. On several other occasions, bleeding was controlled following the administration of oral doses of 5-10 cc. of 6.5% n-butanol solution in water. A. M., a 36-year-old man, had multiple pulmonary metastases from a primary malignant melanoma of the left foot. On several oc¬ casions, hemoptysis occurred and during three of these episodes bleeding was profuse. 5 cc. of n-butanol in saline administered intra¬ muscularly stopped two of these episodes rapidly, but in the third, an injection of 10 cc. intravenously was needed ten minutes after an initial intramuscular dose. Although the intramuscular injection was ineffective, the bleeding was halted within two minutes after intra¬ venous administration. In a report in 1951 in “Angiology,” (193) we presented the following statistics concerning the control of hemorrhage in cancer cases:

Google

UNIVERSITY OF MICHIGAN

THERAPEUTIC

APPROACH

Group I Untreated Number of cases observed 256 Number of cases with profuse hemorrhage 18 Percent of cases with profuse hemorrhage 7 Number of deaths attributed to hemorrhage 12 Percent of deaths in cases with profuse hemorrhage *67

/

443

Group II n-Butanol 344 25 7 1 4

• Death attributed directly to hemorrhage. Since then, these results have been consistently confirmed. Additional progress was achieved with organic acids added to butanol in adequate amounts. Completely non-toxic in the dosages used, they were observed to enhance the hemostatic effect of butanol. This hemostatic effect has been confirmed many times, particularly in Europe where, fol¬ lowing our research, butanol has been widely used as a hemostyptic agent. A hemostatic effect was also evident when butanol was used with the principal aim of controlling pain in postoperative cases. The hemostatic effect was especially important in cases where pathological bleeding usually represented a major complication, either because of the impossibility of obtaining hemostasis during operation or because the surgical wound could not be kept aseptic, as in tonsillectomy, prostatectomy and plastic surgery of the nose. In a study on the use of butanol for postoperative care in ton¬ sillectomies, B. Welt has been able to show a preventive effect, and more important, a hemostatic one if hemorrhage occurs. (187) (Fig. 91) In prostatic surgery, the amount of bleeding was so reduced, that of a group of 40 cases, only one needed transfusion while in a similar number of controls, 8 had to have transfusions. (189) Still more impressive results have been noted in pathological hemor¬ rhages following plastic surgery, especially of the nose. In a significantly large number of cases, severe hemorrhages tend to occur around the 7th day after operation. We have discussed above the pathogenesis of these hemor¬ rhages and the relationship to the allergic defense mechanism. Such hemor¬ rhages have been difficult to control. The use of antibiotics has only partially reduced their frequency and gravity. S. Scher has obtained very good results with the administration of butanol in such cases, using an injection of 5 cc. of a 6.5% solution of butanol once before surgical in¬ tervention and four times daily for two days afterward, followed by oral administration of 15 cc. or one tablespoon four times a day for eight days. No hemorrhages occurred in more than two thousand cases treated. In a

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

444

/

RESEARCH

IN

PHYSIOPATHOLOOY

few patients who neglected to take the medication, and in whom a hemor¬ rhage appeared, bleeding was rapidly controlled by butanol. (Note 6) Experimental Research on the Hemostyptic Effect: In a series of studies we sought to find the mechanism by which butanol controls hemorrhage. In an investigation carried out in our laboratory, M. Bier and P. Teitelbaum (194) showed that individual members of the homologous series of aliphatic alcohols decrease the degree of retraction of clots when added in vitro to blood. (Figs. 141 to 143) By varying the amounts added, this effect was observed to occur only at values above a critical concentration of the alcohol in blood. Bier could show that the critical value, which differs for members of the homologous series, is proportional to the lethal toxic dose in mice. This non-retraction of clots in vitro also can be recognized in cases treated with butanol through the gelatinous aspect of the clots at the mo¬ ment when the hemorrhage stops. However, it is interesting to note that the amount of butanol injected, considered in terms of the amount of the circulating blood, results in concentrations considerably below the critical values needed to produce this effect in vitro. However, concentration of butanol at the site of the wound may explain this. It is also of interest that the same gelatinous character typifies the clots which remain attached to bleeding lesions in animals treated with butanol. In mice, when a portion of tail was cut and butanol was used, the abnormally long clot remained adherent to the wound, differing from that seen in controls. In spite of changes in the clot, it seems that the effect upon the blood itself, and its coagulation in a wound, represents only one of the means through which butanol controls hemorrhage. The speed with which butanol acts, often within seconds after intravenous injection, is much greater than blood coagulation time. Consequently, changes in clot formation alone do not appear sufficient to explain the mechanism through which the rapid hemostasis occurs. M. Bier and H. Lemer in our laboratory studied the influence exerted by butanol upon hemorrhage induced by the highly active proteo¬ lytic enzyme, ficine. (195) They were able to induce standardized hemor¬ rhages by injecting ficine solutions under the skin of the abdomen of white mice. (Fig. 151a) (In other animals and with other sites of injection in mice, the individual variations were too great to make the resulting bleeding use¬ ful as material for testing the effect of agents upon hemorrhage.) With adequate doses of ficine, severe hemorrhages followed by skin ulcerations were induced. The bleeding, and even the ulcerations, were almost entirely prevented when butanol was administered. Figure 151b shows the results of

Digitized by GOO^iC

UNIVERSITY OF MICHIGAN

THERAPEUTIC

APPROACH

/

445

Fic. 151a. Shows graded extent of hemorrhagic infiltration obtainable with progres¬ sive amounts of ficin injected subcutaneously in the abdominal region in mice.

F:o. 151b. The influence exerted by butanol upon the hemorrhage induced by ficin in¬ jection. Top Row. Comparative group treated with butanol. Last animal in each row shows the external appearance of the site of the injection while in others, the skin flap was separated. Bottom Row: Ficin injected animals.

Original from Digitized by

UNIVERSITY OF MICHIGAN

446

/

RESEARCH

IN

PHYSIOPATHOLOGY

this experiment, with the manifest differences, following ficine injections, between animals receiving butanol intraperitoneally and controls. The antifibrinolytic activity of butanol (196) could explain its inter¬ vention in protracted bleeding, and especially in cases where the effect of butanol appears after hours or days. However, inhibition of fibrinolytic activity cannot be conceived to intervene in an action taking place in less than a few minutes. In trying to explain butanol’s antihemorrhagic effects, we also consid¬ ered its pharmacological activities. We have noted the action of butanol upon the acid-base balance of abnormal tissues, as shown by changes in the pH of the second day wound crust. In abnormal tissues, butanol reduces local pH but it does not do this to any great extent in normal tissues. This led us to investigate the difference in the influence of butanol upon pathological hemorrhages. The immediate bleeding induced by standard cutting of the tail in mice was not constant and, in general, was not markedly influenced by administration of butanol. But there was a marked effect upon hemor¬ rhage induced by the displacement of the clots through mechanical ma¬ neuvers one to two hours after cutting of the tail. In controls, the bleeding lasted almost the same length of time as bleeding from fresh lesions, while in animals treated with butanol, it often stopped in a very short time. These data, although interesting, did not seem to offer a completely satisfactory explanation of the mechanism by which butanol stops bleed¬ ing, especially in cases in which it acts within minutes or less. It appeared improbable that the formation of a clot alone would stop the hemorrhage under these conditions. An interesting observation led us to another hy¬ pothesis. In several patients with wide ulcerations, we were able to examine the hemorrhaging vessel after bleeding had been stopped by butanol. Contrary to all expectations, we found that the artery, which usually was severed transversely, was not buried in a clot but remained almost isolated and somehow separated from it. It seemed that blood vessels themselves might have a role in hemostasis. The intervention of a spasm of the smooth muscles of the vessels was considered. This was indirectly confirmed when a patient with severe and prolonged bleeding from the bed of a prostate after ablation, was treated with butanol. An intravenous injection of 40 cc. of butanol was followed by such violent contraction of the bladder as to expel, with great force, the catheter together with clots and urine present in the bladder. At the same moment, bleeding, which had persisted for more than a week, stopped suddenly. We connected this sudden spas¬ modic contraction of the smooth muscles in the abnormal bladder with

Google

UNIVERSITY OF MICHIGAN

THERAPEUTIC

APPROACH

/

447

the injection of butanol and considered that butanol might produce a spasm of the muscular walls of abnormal blood vessels—abnormal because of the hemorrhagiparous condition itself. This would explain the rapidity of the hemostatic effect and the selective action upon small and medium arteries with important muscular walls. In fact, we saw that, while very severe arterial hemorrhages were completely stopped in less than one minute after an intravenous injection of butanol, the same effect was not obtained in oozing bleeding. We tried to investigate further this spastic effect upon blood vessels as the mechanism in butanol hemostasis. Experiments with isolated aorta preparations of rabbits and rats showed that a spastic effect cannot be in¬ duced by butanol, even if the vessels previously have been harmed by manipulation. This can be explained by the fact that the aorta does not have muscular fibers. The same lack of spastic effect is seen in normal arteries of the hind legs of rats and frogs. The administration of butanol to an animal after a small branch of the mesenteric artery was first crushed and, after some time, cut, produced a spastic effect which transformed the jet-like hemorrhage into an oozing one, greatly reducing the blood loss. The hypothesis of vascular spastic contraction as the mechanism in butanol hemostasis has received further indirect confirmation through the study of the effect of butanol upon hemor¬ rhage induced by single traumatic lesions in various organs. Differences were observed according to organs or tissues affected. While bleeding liver wounds are influenced only to a small degree by intravenous administra¬ tion of butanol, hemorrhage from a kidney wound stopped rapidly. The fundamental difference between the liver portal circulation with minimum muscularity of the vessels, and that of the kidney, where highly developed artery muscular layers are seen, can explain the unequal response to butanol. As we can see in these cases, the contraction of a pathological artery can insure rapid hemostasis and accords with the fact that the artery is not buried in a clot. This explains why, especially in clinical application, butanol is more active upon arterial hemorrhage and much less active upon capillary bleeding. This mechanism also would explain the same good effect upon hemorrhage from veins with important walls. Failure of butanol seen in three cases of hemorrhage from varices of the inferior esophageal veins can be explained by the almost complete lack of muscular layers in these varicose veins, which would bar a vasculo-muscular contraction. Parallel to these studies, other possible hemostatic mechanisms have been investigated. We tried to interpret the unusual fact that butanol

Google

UNIVERSITY OF MICHIGAN

448

/

RESEARCH

IN

P HY S IO PA THOL OOY

stopped hemorrhage while agents such as nikethamide, thiamine, isamine blue, sterols and glycerol induced bleeding—yet all have positive polar groups in their molecules, represented by an amine or amide radical for most of them and by hydroxyls for glycerol and sterols. As we have men¬ tioned before, all agents with such positive radicals induce a shift toward less alkaline values for the second-day-wound-crust pH. Therefore, this could not be considered to be the factor that determines the antagonistic effects on bleeding. The aliphatic or cyclic character of the nonpolar group does not seem to be a factor since glycerol and butanol both have aliphatic chains. However, correlation with another biological effect could be noted. All the substances with hemorrhagiparous effect, also produce a convulsive effect if administered in sufficiently high doses. The convulsive effect of Coramine and thiamine has been known for a long time and we used these substances any time we wanted to induce experimental convulsions. We also have seen that convulsions can be consistently induced in animals through the use of relatively large doses of glycerol or sterols. Convulsions in several human cases have followed the use of these agents. Doses as high as 20 cc. of a 5% solution of the insaponifiable fraction of placenta or of the 2% solution of cholesterol in oil, administered for therapeutic pur¬ poses have induced convulsions in patients, with a previous history of convulsive seizures. A convulsive effect in animals has been noted for all the agents mentioned above which also have hemorrhagiparous activity. We were able to induce convulsions in rats, even by injecting 20 cc. of a solution of 10% glucose subcutaneously once a day for a few days. In humans, we also saw convulsions appearing after glucose was administered intravenously in an amount of 100 gm. in a saline preparation to patients treated concomitantly with desoxycorticosterol, although the last substance has no convulsivant effect by itself. On the other hand, the antihemorrhagic butanol produces a hypnotic effect if administered in high doses. The dose of butanol needed to prevent hemorrhage induced by ficine in mice, for example, was enough to pro¬ voke hypnotic activity comparable to that of barbiturates, chloroform and even ether. Very interesting is the fact that these agents also are able to prevent ficine-induced hemorrhage if administered in doses sufficiently high to produce hypnotic or narcotic effects. The peculiar correlation be¬ tween convulsive and hemorrhagiparous effect on the one hand, and hypnotic and hemostatic effect on the other, provides some further under¬ standing of butanol hemostasis, but does not furnish the explanation for the mechanism through which this hemostasis takes place. The most plausi-

Google

UNIVERSITY OF MICHIGAN

THERAPEUTIC

APPROACH

/

449

ble conclusion is that butanol intervenes through several mechanisms, some inducing immediate hemostasis through arterial contraction, while others have a later effect through changes in the blood clotting process, with lack of retraction of the clot and an influence upon fibrinolysis. Contraction would explain why, with only few exceptions, it is the pathological arterial hemorrhage which responds most favorably to butanol. An immediate influence upon capillary or venous hemorrhage is less mani¬ fest and, in a very few cases, absent. The same is true for traumatic hemor¬ rhages where, although there are some good immediate results, in general they are less rapid than for pathological arterial hemorrhage. Because of its immediate effect upon arterial bleeding, butanol became the agent of choice for those pathological hemorrhages which, through their arterial origin, could be fatal in a short time. One of the big advantages of hemostasis induced by butanol over that obtained through other agents resides in the fact that there is no manifest increase in blood coagulability. Only in concentrations which never can be attained in vivo has butanol been seen to change the coagulability of blood. The inherent danger of thrombosis resulting from high blood coagulability limits the amount of the other agents to be administered. This danger does not exist for butanol and no such limitations are placed upon its use. The fact that normal prothrombin time is uninfluenced by butanol while high prothrombin time is reduced toward normal represents another advantage. In further studies, we tried to enhance the hemostatic action of butanol without increasing blood coagulability. The addition of calcium salts was of no value but an enhancement was seen with potassium salts. In a series of experiments, it was noted that, when a solution of butanol is kept for a long time in a stoppered bottle, its activity increases. For long-standing preparations, 50% smaller doses were sufficient to protect mice against the action of ficine. The narcotic and toxic effects of these preparations also increased in the same proportion. This led us to add butyric aldehyde, the product of immediate oxidation of butanol, which increased butanol’s coagulating effects only very slightly but enhanced its hemostatic effect considerably. The addition of hydrogen peroxide did much the same. Blood Mixed with Butanol, used against Hemorrhages S. Akad, working in our laboratory, showed that the coagulation time of blood is also increased if butanol, mixed previously with blood, is added. In the clinical application of this observation, we used the patient’s own blood extemporaneously mixed with butanol. In a syringe containing, for

Google

UNIVERSITY OF MICHIGAN

450

/

RESEARCH

IN

PHYSIOPATHOLOOY

instance, 10 cc. of the butanol solution, 2-5 cc. of the patient’s blood is withdrawn. After mixing them, and without removing the needle from the vein, the contents of the syringe are injected intravenously. A similar mix¬ ture can be injected also intramuscularly or subcutaneously. The results have been very good. In some cases in which butanol alone was not able to stop a hemorrhage, the blood-butanol mixture did. With this special technique, we have been able, in recent times, to bring most hemorrhages under control within a few minutes. The fact that agents with positive polar groups, such as sterols, glycerol, coramine, thiamine and others, have hemorrhagiparous activity led us to try to influence hemorrhage with agents considered biologically antagonistic through their negative polar group. Many years ago, experimenting with chlorine solutions in saline, we observed a manifest effect upon coagulation time. Intravenous injection of such solutions brought coagulation time to values as low as one minute. The addition of these solutions to butanol greatly increase its effect in vitro upon coagulation time but had less effect upon hemostasis in vivo. Similar but somewhat less manifest effects were obtained by adding hydrochloric acid to butanol solution. On the other hand, organic acids such as oxalic, malonic, citric, lactic maleic or citraconic showed a favorable effect. With¬ out changing coagulability of the blood, these acids were seen to in¬ crease the hemostatic effect. Fatty Acids The same antagonism to sterols and glycerol led us to use fatty acids from cod liver oil. (197) While results in severe large arterial hemorrhages were not impressive, the effect upon oozing capillary, venous and small arterial hemorrhages was very good in a large proportion of cases. For ex¬ ample: N. V., 57 years old, with multiple pulmonary metastatic lesions from a hypernephroma, had frequent hemoptysis. At times, the bleed¬ ing became more accentuated, the patient expectorating clots as well as uncoagulated fresh blood. Intramuscular administration of two doses of 10 cc. of a 6.5% solution of butanol at half hour intervals had little influence upon the bleeding. Intramuscular administration of 1 cc. of a solution of 10% of the mixture of fatty acids obtained from cod liver oil stopped the bleeding in less than 20 minutes, with the effect persisting for more than two months. A new episode of oozing bleeding was again immediately controlled by injection of the fatty acid preparation.

original Trom Digitized by GOOgl.C

UNIVERSITY OF MICHIGAN

THERAPEUTIC

APPROACH

/

451

Other cases with hemoptoic sputum, prolonged bleeding from gastric or duodenal ulcers or from rectal or uterine tumors, all corresponding to oozing rather than to acute massive hemorrhage, have responded to ad¬ ministration of this fatty acid preparation. Almost uniformly, these oozing hemorrhages, which had not responded to butanol, were rapidly controlled. We now use butanol mixed with small amounts of hydrogen peroxide and organic acids mentioned above, to control severe arterial hemorrhages while for the oozing type, fatty acids from cod liver oil are used.

Allergic Conditions Allergic conditions, which as seen above, are related to the defense mechanism, also have been integrated into the general therapeutic ap¬ proach. This has largely permitted us to apply to such conditions the same therapeutic measures used in general. The study of the manifestations has, however, shown that except for the anaphylactic shock, the clinical allergy corresponds to the prolonged phase with the predominance either of sterols or lipoacids. The urinary surface tension has appeared as a valuable cri¬ terion to indicate the occurring offbalance. In cases with a high urinary surface tension, sodium thiosulfate, aldehydes or epichlorohydrin have given particularly good results, while the cases with low surface tension showed favorable response to heptanol and butanol. Food allergies, asthma, urti¬ caria which had persisted for years and were insufficiently influenced even by corticoids—have responded with the complete disappearance of their manifestations with an adequate dose of one or the other of the medica¬ tions mentioned above. In most of the cases kept under continuous treat¬ ment with minimal doses, favorable results persisted even after the subjects were again under the influence of antigens. The following observations illustrate these results. Mrs. M. S., 45 years old, with skin and eye allergic manifestations, highly sensitive for the past six years to fish, eggs, alcoholic beverages, some vegetables and fruits, and especially to dogs, showed no favorable response to corticoids.

With

high urinary surface tension

and high

eosinophiles, the patient was treated with 50 mg. sodium thiosulfate and 2 mg. epichlorohydrin, four times a day. The symptoms decreased pro¬ gressively to disappear in a week. After a month’s treatment, she was able to take—without any inconvenience—foods and alcohol to which she had been previously sensitive. After another two months, the acquisition of three puppies produced no disagreeable effects. The patient has continued

original Trom Digitized by GOOgle

UNIVERSITY OF MICHIGAN

452

/

RESEARCH

IN

PHYSIOPATHOLOCY

on the same treatment, but reduced to twice a day, for the past year with¬ out recurrence of the manifestations. Mr. A. L., 58 years old, had frequent attacks of asthma for over four and a half years which left him unable to work for the past year. Because of low urinary surface tension, the patient was put on butanol—5 cc. of a 6.5% solution in water—to be taken every six hours. Although the first doses showed marked objective and subjective changes, the treatment was continued. The patient was free of attacks for four months at which time he stopped medication. Two weeks after stopping medication, he had an attack, the first in four and a half months and this was followed by another the following day. By resuming the medication, he has been free of symp¬ toms for more than a year. The possibility of preventing allergic manifestations with butanol, which appeared so clear in the traumatic lesions, opens an entirely new view for many conditions where such a pathogenesis intervenes. The concept of a nervous tissue allergy intervening in the pathogenesis of multiple sclerosis, led us to try similar antiallergic treatments. The low surface tension led us to utilize as agents, lipoids with a positive character. Interesting—although not constant—results were obtained with insaponifiable fraction of cow brain. Good results were obtained with butanol—100 mgr. four times a day—together with an antihistamine preparation.

ARTERIOSCLEROSIS One of the most important medical problems from all points of view— pathogenic, therapeutic and even social—since it still represents the chief direct cause of death in most civilized societies, is that of arteriosclerosis. The fact that lipids seem to intervene in its pathogenesis, has led us to con¬ sider this condition from the point of view of biological offbalances. With the development of our research, we tried to apply to this condition a sys¬ tematic analysis in accordance with the basic concepts presented above. This attempt has permitted us to arrive at some new views which will be discussed briefly here. The analysis of the specific manifestations of arteriosclerosis from the point of view of organization, that is, as related to the different levels, led us to recognize that it represents a condition principally limited to the level organism, and more especially to its secondary part, the circulatory system. Many of the fundamental characters of the condition could be explained by the relationship of this level to other levels of the organization, as we will see below.

Digitized b

Google

Original from UNIVERSITY OF MICHIGAN

THERAPEUTIC

APPROACH

/

453

From the point of view of the dualistic concept, it was easy to see that arteriosclerosis corresponds to an offbalance type A. All the analyses con¬ cerning the systemic level show patterns which indicate this offbalance. High urinary surface tension, low urinary specific gravity, high urinary pH, low urinary sulfhydryl index, found in the routine analyses point to such an offbalance. The long persistence of the skin wheal seen in the subjects analyzed, confirms this diagnosis. The fact that some manifestations of arteriosclerosis can be induced experimentally in animals through the ad¬ ministration of cholesterol, has placed into limelight the pathogenic role of cholesterol. While its administration in high amounts to rabbits or cockerels induces atheromas, it does not induce the complex condition itself. Usually the animals return to normal, even with a rapid healing of their atheromas after the suppression of the administration of cholesterol. Although hyper¬ cholesteremia represents thus only one pathogenic factor, it appeared in¬ teresting to investigate its intervention in the condition. The relationship of cholesteremia to arteriosclerosis is certainly not a simple one. The total amount of cholesterol in blood alone, in its free form, and the macromolecules of certain dimensions resulting from their bond to the other constituents of the blood, although related to arteriosclerosis, do not seem to represent by themselves the pathogenic factor of this condi¬ tion. This latter seems to be related to a more specific intervention of this substance at the level of the blood and circulatory system. Research in this field has led us to recognize this special intervention. It is a known fact that the appearance of crystals of cholesterol in the cells of the intima of the arteries and in the cells of the vasa vasorum repre¬ sents an essential factor in the pathogenesis of atheromas. Study of the capacity of blood serum to dissolve or, on the contrary, to precipitate cholesterol has permitted to link it with the appearance of specific arterial lesions in this condition. In this study, we used the procedure originally devised by Policard when he investigated the relationship of cholesterol and arthritis. Blood is obtained through veinous puncture and the serum is separated aseptically. The amount of total cholesterol is determined in the blood serum. A sterile crystal of cholesterol is added to the serum. The treated serum is incubated for 6-12 hours at 37°C. The serum is then separated through filtration from the crystal added, or from those formed during the incubation. The differ¬ ence between the amount of cholesterol in the serum before and after incubation with the crystal, shows that while some sera increase their con¬ tent in cholesterol through this treatment, others decrease it. We could show that the serum of those rabbits which were fed with

Digitized by

Google

original irom

UNIVERSITY OF MICHIGAN

454

/

RESEARCH

IN

P HYS IOPATH OLOO Y

two grams of cholesterol daily and which have a tendency to make ather¬ omas, precipitates cholesterol. Oppositely, the resorption of atheromas seen in rabbits after the suppression of the feeding with cholesterol, was seen to occur together with the blood serum capacity to dissolve cholesterol. The relationship between this capacity to precipitate cholesterol and the ap¬ pearance of atheromas was confirmed by the fact that it could not be seen in rats fed with cholesterol, where atheromas appear very seldom. Further it was seen present in subjects prone to make vascular occlusions. The ad¬ ministration of high amounts of cholesterol to animals with tumors has led to the appearance of vascular occlusions followed by ischemic infarcts in the tumors. The occlusion could be related to the proliferation of the arterial endothelium and the capacity to precipitate cholesterol.

*

Days

Fio. 152. The incubation of citrated blood at 37°C changes only little the amount of cholesterol in Case (a), while it determines a rapid decrease in Case (b).

In a further study of the cholesterol in blood, we investigated the capacity of the different samples of blood to cause their cholesterol to dis¬ appear after incubation at 37°C. We could show that while some samples of citrated blood kept at 37°C under sterile conditions, decrease their cholesterol content rapidly, others do not change it even after days of in¬ cubation. Figure 152 shows two such examples. We could also show that in rabbits fed with cholesterol and having atheromas, their blood lacked the capacity to make cholesterol disappear after incubation, differing from what was observed in the majority of the controls. We then studied in another group of researches, the relationship be¬ tween red cells and their cholesterol content. We could show that by wash¬ ing red cells with saline, they lose their cholesterol. By using saline in amounts corresponding to the plasma, this effect could be measured. How-

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

THERAPEUTIC

APPROACH

/

455

ever, while in some bloods a manifest loss in cholesterol occurs with the first or second washing, in others the loss occurs very slowly. Sometimes ten such washings are necessary before the cholesterol is low enough to start hemolysis. Figure 153 illustrates two such examples. We could show that the red cells of rabbits fed with cholesterol demonstrated a higher capacity to retain cholesterol throughout saline washings, than did red cells of normal animals. The analysis of arteriosclerotic cases from the point of view of this relationship between blood and cholesterol has shown that the tendency to precipitate cholesterol, coupled with a low capacity to make it disappear through incubation, is encountered in those cases prone to acute episodes

Cholesterol

of vascular occlusion.

Fio. 153. The washing of human red cells with saline induces a very slow decrease in their content in cholesterol in Case (c). The hemolysis starts in this case at the 10th washing. In Case (d), such an effect appears after the second washing.

The big differences seen in the behavior of blood towards cholesterol has raised the problem of its relationship from an organizational point of view. The application of the concept of a proper level in the organization to cholesterol has permitted us to interpret the occurring changes. Cholesterol represents a cellular constant and the classical studies of Shaffer have shown the importance of its amount in the cells. The quantity of water retained by the cells is largely determined by the ratio between choles¬ terol and fatty acids of the cells. Under this aspect, we have hypothetically considered hypercholesteremia as corresponding to a kind of defense re¬ sponse of the blood level toward the changes occurring at the level below it, respectively toward an opposite lipidic offbalance occurring at cells, tissues or even organs. We investigated hypercholesteremia under this specific

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

456

/

RESEARCH

IN

PHYSIOPATHOLOGY

aspect. We have seen above that in the lipidic system, sterols correspond to an anti-fatty acid agent. This led to the supposition that hypercholes¬ teremia could represent a response at the blood level to changes taking place at a lower level in the relationship between fatty acids and cholesterol. A first fundamental finding in this direction was the fact that the amount of cholesterol in the blood represents—as shown for potassium, copper, hydrogen ion concentration/ etc.—values which, while maintained constant by a regulatory system, vary very widely under different circumstances. These wide variations would correspond rather to a secondary response. The amount of blood cholesterol would change as a secondary constant. A balanced system of manufacturing and excreting insures the maintenance of this secondary blood cholesterol amount. In the case of cholesterol, the manufacturing factor seems to be represented by the R E S cells, while the excreting factor by the liver, primarily by the Kuppfer cells and secondarily by the hepatic cells, the cholesterol being ultimately excreted in the bile. We do not know the factor which directly changes the manufacturing or excretion of cholesterol in blood and which consequently maintains its balance. By analogy we consider the changes in blood cholesterol value to result from those occurring at the lower levels as seen for other sub¬ stances such as potassium, or copper, for which blood does not represent the proper level. According to this view, with cholesterol having the cellular level as its proper level and the blood as superior level, the blood changes would reflect secondary responses to those occurring at lower levels. We saw such changes at the cellular level in old age. We could find thus that organs of old animals, perfused with saline to wash them from their blood, are richer in fatty acids and poorer in sterols than those of young individuals. The cellular lipidic abnormality, corres¬ ponding to aged persons, would correspond to a quantitative predom¬ inance of fatty acids. Their analysis showed that these fatty acids correspond qualitatively to those normally encountered in the organisms and especially to the polyunsaturated members. It should be noted at this time that this predominance differs from that found in abnormal conditions which cor¬ responds to offbalance D. In this latter case, the fatty acids are abnormal. With the concept that cholesterol belongs to the cellular level, we studied as we did for potassium (See Chapter 5 Note 2), the concomitant changes in the amount of free cholesterol in plasma and in red cells. This was car¬ ried out to obtain information concerning the relationship between choles¬ terol and abnormal conditions. While a high or low amount in both plasmatic and cellular cholesterol would indicate an excess or lack of this substance, the discordance between these two data would correspond to

Digitized by

Google

uriumdi Hum

UNIVERSITY OF MICHIGAN

THERAPEUTIC

APPROACH

/

457

an offbalance. A high cellular, with a relatively normal or low plasmatic cholesterol, corresponds thus to an abnormal cholesterol offbalance pre¬ dominant at the cellular level, while a relatively low cellular and high plasmatic cholesterol, to the opposite offbalance. By now considering choles¬ terol in its anti-fatty acid role, these changes permit further interpretation. As we have seen above, cholesterol corresponds rather to the anti-fatty acid constituents controlling the normal polyunsaturated fatty acids and thus differs from the corticoids which represent agents opposing the ab¬ normal fatty acids. The ultimate cause of hypercholesteremia would logically be sought in a quantitatively abnormally high amount of qualitatively normal fatty acids present at the lower levels. Although hypercholesteremia represents by itself only a response to a fatty acid offbalance taking place at lower levels, the high amount of sterol present in blood can cause, by itself, a series of disagreeable manifestations. Hypercholesteremia can thus induce noxious manifestations although, tele¬ ologically speaking, it is directed to correct an offbalance at a lower level. The effect of this chronic richness in blood cholesterol is manifested in the circulatory system and atheromatosis appears as an immediate result. The precipitating tendency for any new increase in blood cholesterol explains the appearance of crystals in the cells of the intima and secondarily the ap¬ pearance of atheromas. Therapeutic Attempts This pathogenic concept of arteriosclerosis presented above, has guided our therapeutic approach. As early as 1942, we used acid lipidic fractions of organs in a tentative therapy to control hypertension and indirectly arteriosclerosis, with interesting immediate results. We learned however, that not only were the effects temporary but also that after some time, the administration of unsaturated fatty acids induced a progressive increase in the amount of cholesterol present in blood. The concept of hypercholesteremia as a secondary blood response to a cellular fatty acid predominance explained this occurrence and led us also to the further development of this approach. With cholesterol as an anti-fatty acid agent which appears in high amounts in blood, as a response to an excess of fatty acids at the cellular level, we tried to influence this secondary response by acting on the existing primary cellular offbalance. A decrease of this response could be obtained by supplying substances other than cholesterol, acting as anti-fatty acid agents. If the cellular fatty acid offbalance can be controlled, the organism as an entity would no longer be obliged to respond to the occurring offbalance and manufacture blood

Digitized b

Google

UNIVERSITY OF MICHIGAN

458

/

RESEARCH

IN

P HY S IOP ATH OLOO Y

cholesterol in excess. Without this need, hypercholesteremia will no longer appear. Under these conditions, the administration of anti-fatty acids has appeared as the logical way to prevent and even to combat an existing hypercholesteremia and its consequences. Choice of the Anti-Fatty Acid Agent The next problem was the choice of an adequate anti-fatty acid agent. It appeared advisable to use more than one such agent. One would in¬ tervene at the lower cellular level where the primary factor—predominance of fatty acids—exists; another would act at the level of the tissue and blood itself where their presence would act as an anti-fatty acid and prevent more directly the further appearance of cholesterol. These considerations led us to utilize as active agents, heptanol, glycerol and polyunsaturated alcohols for the tissue level. Butanol was added, being more active at the organ and systemic levels. We found that mixtures of these alcohols were advisable also in view of the plurality of fatty acids intervening in this abnormal condition. Mixtures of polyunsaturated fatty alcohols were obtained through treatment with lithium aluminum hydride, of the fatty acids present in cod liver oil, fish oil, safflower oil, sesame oil, or even in the lipoacid fraction of organs. Clinical Results The best clinical results were obtained with a preparation having in its constitution, glycerol, polyunsaturated fatty alcohols, heptanol and butanol. In a series of subjects with persistent high amounts of cholesterol in blood, the administration of this preparation brought the blood choles¬ terol to low values. The following observations are characteristic. Mr. M. R., 60 years old, had high cholesterol in the blood for ten years, with values above 350 mgr. %, in spite of severe diet poor in fats and cholesterol. Administration of unsaturated fatty acids brought the blood cholesterol, for a short time, to values between 260 mgr. and 300, returning to values above 350 after cessation of medication. Wtih the mix¬ ture—glycerol, polyunsaturated fatty alcohols, butanol and heptanol—the blood cholesterol went down to 150 mgr. % in less than two weeks without any side effects or restricted diet, and with a manifestly good general con¬ dition. It remained at this level for the 5 months of observation with only minimal and irregularly taken medication. L. N., 70 years old, with blood cholesterol varying in recent years between 400 mgr. and 280 mgr. in spite of low fat and low cholesterol diet and different treatments. The mixture of glycerol, fatty alcohols, heptanol

Google

Original from

UNIVERSITY OF MICHIGAN

THERAPEUTIC

APPROACH

/

459

and butanol, brought it down in three weeks to 160 mgr. It remained around this value for more than the six months of observation with no special diet and with only a very small amount of medication. In a group of 20 subjects with cholesterol above 350 mgr. %, a descent of the cholesterol to values below 250 mgr. % was obtained in all the cases, with a treatment ranging from 10 days to 3 weeks. No inconveniences were observed. Coronary Occlusion The coronary occlusion with the consequent myocardial infarction represents the most important complications of arteriosclerosis. Death can occur instantaneously. In these cases it can be considered to result from a lesion of such localization or dimension as to be entirely incompatible with the function of the heart. When death occurs, not instantaneously but at any time after the occlusion has taken place, other factors have to be considered as intervening and leading to the fatal issue. Shock appears to be the most important one. Superacute shock, with death in a few minutes, an acute shock with death in 1-2 hours, or state of shock with death within hours or days, represent the other important intervening pathogenic factors added to the infarction itself. As seen above, these types of shock corres¬ pond to oflfbalances of the type D, this time with a predominance of ab¬ normal lipoacids. A therapy with anti-fatty acid agents represents as shown above, the intervention which could prevent or reduce shock. While the administration of sterols appears contra-indicated, since it would increase the vascular occlusion, that of the non-sterolic anti-fatty acids is especially advisable. The effect of these anti-fatty acid agents upon pain and the other symptoms which are of alkaline pattern, as well as upon the evolution of the condition, has fulfilled our expectations. We attributed an important role to glycerol in these cases. Its action similar to an anti-coagulant but limited to the level of the existing lesions, was able to prevent further local thrombosis without, however, the danger of a general reduction of blood coagulability. Administered in adequate amounts, guided by the pattern analyses, the mixture of the anti-fatty acid agents mentioned above has been followed by manifest clinical improvements. L. K., 58 years old, with a history of several myocardial infarctions, was seen in a very severe state of shock. The electrocardiogram showed that besides the old lesion in the posterior wall, a new infarction of the anterior wall was present. Butanol was administered in doses of 5 cc. of the 6.5% solution together with 0.1 cc. glycerol every hour until the complete

Digitized by

Google

unnma rrom

UNIVERSITY OF MICHIGAN

460

/

RESEARCH

IN

PH YSIOP ATHOLOCY

cessation of symptoms and was continued 4 times a day afterward. The favorable effects continued in an unexpected form, the patient being without pain in less than 3 hours and without symptoms the third day. The choles¬ terol was found to be 135 mgr. % the fifth day. This view of arteriosclerosis opens a new way for further research con¬ cerning many pathogenic problems, and a logical therapeutic intervention in this condition.

Digitized by

Goo

Onginal from

UNIVERSITY OF MICHIGAN

CHAPTER

THERAPEUTIC APPROACH TO CANCER

One of the ultimate aims

of our research has been to try to utilize

in cancer the knowledge obtained from investigations of the general prob¬ lems of pathology and therapy. Encouraged by the results of biologically guided therapy in many other conditions, we have applied it to the treat¬ ment of malignancy. As we have mentioned before, differences between animal cancers, both experimental and spontaneous, and human cancers represent one rea¬ son why an agent, however good its results in animals, may not apply to human malignancy. Another factor, conduct of treatment, is no less im¬ portant. The main characteristic of our therapeutic approach resides in the fact that treatment is continuously guided by data representing the actual condition of the subject. At least for the moment, it appears impossible to recognize, through suitable tests, the patterns present in animals so as to apply them to guided therapy. Therefore, we have been obliged to do our therapeutic research in humans, reserving animal studies for limited prob¬ lems. This situation had led us to emphasize, always, the experimental nature of our therapeutic efforts in humans. Although we started with desperate terminal cases, frank immediate subjective and objective benefits, even though temporary, were obtained frequently enough to encourage us to go on. Together with the above mentioned considerations, they seemed to justify the continuation of therapeutic research in human patients. We will try to review as objectively as possible the results obtained with therapeutic methods and agents evolved over the years. In 1927, a 33-year old woman with typical preterminal cancer of the stomach came under our care. In the highly emaciated patient, a hard, 461

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

462

/

RESEARCH

IN

PH Y SI O P A THOL OOY

irregular mass filling the entire epigaster was palpable. Radiological ex¬ amination indicated a prepyloric gastric tumor. Laparotomy showed an inoperable tumor of the stomach, with the omentum and lymphatic glands greatly involved and evidence of multiple peritoneal and liver metastases. In view of the patient’s general condition and the fact that the pylorus was only partially obstructed, no surgical procedure was performed other than biopsy of one of the metastases in the omentum. The biopsy showed an adenocarcinoma Grade III of gastric origin. Treatment was not prescribed. I saw the patient two years later in apparently good health. Clinical and radiological examination at that time showed no tumor. The patient attested to receiving no treatment. At the time of the operation she had been two months’ pregnant. We had attributed her amenorrhea at that time to the advanced cachectic condition. She had given birth at term to a normal girl. Hers was one of those cases usually catalogued as “spontaneous remission.’’ Since then, I have analyzed many of the published observations of cases of so-called “spontaneous remission’’ of cancer always to find a turn¬ ing point that coincided with the intervention of some event usually con¬ sidered to have no possible significance for malignancy. The fact that such events have not induced similar changes in other cancer patients has made them seem unimportant to many investigators. While not regarding them as the only cause of favorable changes, we have not eliminated the possibility that such events may have a contributory role. We must recognize that, if such events in themselves appear to be powerless to change the course of cancer, they may intervene in conjunction with, and potentiate, another factor also powerless in itself to induce a change. It was with this concept in mind that we reviewed the case of the woman with stomach cancer. We considered the possible effects of two factors which apparently intervened concomitantly: pregnancy and surgery. We then began a series of experiments. Ehrlich mammary carcinoma was grafted in two groups of female mice, one pregnant and the other not. In each group, half of the mice were kept as controls while the other half was submitted to a sham surgical procedure consisting of a laparotomy in which multiple ligatures were performed. Growth of the tumors and survival times were noted. Compared with nonoperated, nonpregnant mice serving as controls, both the pregnant mice and the surgically treated mice showed a slowing down in the evolution of cancer lesions. It was in the group of mice, both pregnant and surgically treated, that a temporary arrest in tumor evolution was seen. In some ani-

Google

UNIVERSITY OF MICHIGAN

THERAPEUTIC

APPROACH

TO

CANCER

/

463

mals even temporary regression was noted; in 1/20 the tumor regressed entirely. Placenta Extracts These experiments led us to try an extract obtained from placenta autol¬ ysates which, in our opinion at the time, would reproduce, up to a point, some of the conditions present in these experiments. Human placentas were autolyzed by being maintained from several hours to a few days at 37° C, and an alcoholic extract was obtained. The alcohol was eliminated through distillation in vacuum. The residue proved non-toxic in animals and was injected intramuscularly in some terminal cancer cases. Impressive results were observed in the first cases. Pain was markedly diminished and, in some instances, disappeared entirely. Objective changes in the tumors could be noted. While only temporary results were seen for most of these cases, for some the results appeared to last a long time. Their number would exclude pure coincidence. Mr. H. B., 56 years old, came under our care with a cancer involving more than half of the right part of the tongue. Multiple large submaxillar and cervical gland metastases were present, two of them being approxi¬ mately 8 cm. in diameter. The mouth lesion was very painful and bled occasionally; there was moderate pain in the ganglionar metastases. A biopsy performed at a much earlier stage had shown a squamous carci¬ noma. Considered inoperable, the subject had not received any treatment except for pain palliation. We administered daily intramuscular injections of 5 cc. of the placenta extract. Except for a limited local reaction at the site of injection, no dis¬ agreeable effects were seen. On the contrary, after each injection, the pain in the tongue was reduced for a few hours. It disappeared entirely after one week of treatment. During the second week of treatment, the tumor of the tongue, as well as the metastases, began to decrease in size. The local reaction at the site of the injections increased, however, to such an extent that we were obliged to stop treatment after 5 weeks. In spite of this, the lesions continued to decrease so that the tongue tumor was no longer palpable after two months. At that time, the gland metastases were reduced to approximately one and a half centimeters in diameter. The patient’s general condition was much improved and he gained weight. In another month, except for a scar on the tongue, no other pathology could be found. We followed this case without treatment for another year and a half during which time there was no recurrence. After that, the patient left town and we were unable to reestablish contact with him.

Digitized by

Google

onginai rrom

UNIVERSITY OF MICHIGAN

464

/

RESEARCH

IN

P H Y S I O P A TH OL OGY

Mrs. B. A., 44 years old, came under our care with a massive tumor filling the entire vagina. The condition had been diagnosed 8 months pre¬ viously as carcinoma of the cervix which had invaded the parametria and was propagating toward the vagina. A biopsy made at that time indicated squamous carcinoma Grade III. As the patient was considered inoperable and refused any other treatment, only sedation was prescribed. When we examined her, the tumor was protruding from the vagina as a hard mass. Rectal examination revealed invasion of the entire recto-vaginal wall. The patient received a daily injection of the placenta extract preparation for 45 days, after which she interrupted the treatment. The pain had been entirely controlled in less than a week, but no other changes had been observed. She returned three months later, having received no treatment in the interval. Examination revealed complete disappearance of the vaginal tumor, with the cervix entirely replaced by soft scar tissue. We followed this case for two years, during which no further treatment was given and the patient showed no recurrence. Mr. A. N., 40 years old had an extensive cancer of the cheek, with massive ulceration resulting in a large communication between oral cavity and exterior. Occasionally small hemorrhagic episodes were experienced. The patient had had several courses of radium therapy. When he came under our care, he had multiple lesions, and several biopsies performed at that time revealed active carcinoma in all lesions tested. The patient re¬ ceived intramuscular injections of 5 cc. of the placenta extract preparation daily for 17 days. A massive hemorrhage occurred at this point, treatment was stopped, and he went home without further medication. When the patient returned three months later, scar tissue covered all areas where the tumor had been seen previously. Clinically no trace of tumor could be found. In a few months, the patient’s condition was good enough to allow his surgeon to attempt a skin graft to cover the big opening in the cheek. This was not successful. The graft from the skin of the neck unfortunately underwent necrosis. In several other cases, similar subjective and objective changes were observed with use of the same alcoholic extract of human placenta autol¬ ysates. During this time, we attempted to substitute cow placenta, utilizing both fetal and maternal parts, which are easily separable in the cow. In a relatively small number of cases in which these products were used, we could see no differences in the influence of placenta extract according to origin. Poorer results were obtained with extracts using fresh placenta in-

Digitized by

Goo

UNIVERSITY OF MICHIGAN

THERAPEUTIC

APPROACH

TO

CANCER

/

465

stead of the autolysate. However, certain interesting clinical results indi¬ cated that fresh placenta still has a capacity to influence what can be considered to be the normal course of cancer. The following case is an example. Mrs. C., 54 years old, had a tumor of the rectum which was considered inoperable. Only a colostomy was performed. Pain was slight and no other treatment was instituted. Several months after the colostomy, the patient came under our care. At that time, the tumor filled the entire rectal am¬ pulla. Treatment with the fresh cow placenta alcoholic extract was started, using intramuscular injections of 5 cc. daily. After less than a month of treatment, the tumor diminished in size, leaving a small passage for the examining finger. After another month and a half, the tumor had entirely disappeared and the rectal ampulla was wide open. Proctoscopic examina¬ tion showed only normal mucosa. This case was followed for two and a half years with no evidence of recurrence. Thereafter, because of the war, we lost touch with her. In spite of such results in a few cases however, extracts of fresh placenta were judged to be much less effective in general than extracts of placenta autolysates. At the beginning of our research, still unaware of the dualism inter¬ vening in cancer pathogenesis, we observed a series of cases in which the placenta preparations in general produced undesirable results, such as in¬ crease in pain intensity. Furthermore, when used in higher doses over a longer period of time, it induced new pains which clearly increased with each subsequent injection. For a while, this fact made us limit the use of the product to only those patients showing favorable responses in pain, until we could find an explanation for these paradoxical results. With the progress of our research and recognition of dualism in the pathogenesis of pain, we limited the use of the placenta extracts to patients with an acid pattern of pain. This improved the subjective and objective results, and reduced the cases in which undesirable effects occurred. In over 100 terminal patients treated with this preparation between 1935 and 1938 in different hospitals in Paris, objective improvement was observed in 20%. In a few, tumors disappeared. Acid pattern pain was relieved. In many of these cases, however, after a period in which the tumor decreased in size, or even clinically disappeared, it started to grow again and could not be influenced by further treatment. Furthermore, when the dose was increased, other pathological manifestations appeared. The following cases are examples. Mrs. B. B., 42 years old, came under our care with severe pain result-

Digitized by

Goo

UNIVERSITY OF MICHIGAN

466

/

RESEARCH

IN

PHYSIOPATHOLOOY

ing from a widely ulcerated cancer of the cervix involving the parametria and the vagina. 5 cc. of the cow placenta extract was administered daily and the patient remained without pain for almost three weeks, after which time the pain returned. An increase in dosage—to two injections of 5 cc. daily and then to two injections of 10 cc. daily—resulted not only in an increase in pain but also caused the appearance of an abundant watery vaginal discharge. In a few days this reached several liters a day. Despite the fact that we stopped treatment, the exudate continued to increase. At one point, it amounted to 8 liters in 24 hours. The very concentrated urine was reduced to less than 200 cc. in 24 hours. The patient died in ten days in spite of all attempts to stop the excessive secretion. Mrs. G. L., 48 years old, had a radical mastectomy for a left breast adenocarcinoma. A rapidly growing local recurrence was seen 6 months later. The patient came under our care with an ulcerated tumor occupying the entire left half of the chest. Administration of 5 cc. of cow placenta extract for two weeks not only increased the burning sensation present but caused the appearance of an abnormally abundant watery exudate. As is often true in such cases, an infection with B. pyocyaneus was seen. A clear fluid was observed surging in drops from the ulcerated lesion. By weighing the dressing, the amount excreted was measured and found to exceed 10 kilos a day. Despite use of saline infusions, calcium preparations, vitamin C in high doses, atropine, and other measures, the patient expired in less than a week. The appearance of such complications, the frequent changes toward alkaline patterns of pain, and the increase of intensity of alkaline pattern pain, made us reduce and ultimately stop use of these placenta extracts in spite of some good results obtained. Cod Liver Oil Fatty Acids and Sterols At the same time, progress in our research had led us to recognize, in addition to dualism in the pathogenesis of many manifestations, the special role played by lipids. In 1938, we began to use two groups of an¬ tagonistic lipids, fatty acids and sterols. We started with a mixture of fatty acids prepared from cod liver oil for one group and with cholesterol for the other. Later we utilized only the polyunsaturated members from the group of cod liver oil fatty acids. Fatty acids were administered intramuscularly in oily solutions or in gelatinous capsules by mouth. As with administration of placenta extract, the immediate effect was favorable on pain of an acid pattern, and adverse on alkaline pain. In both cases, the effect occurred in a few minutes. Thera¬ peutic attempts with fatty acids were consequently limited to patients with

Digitize

Google

Original from

UNIVERSITY OF MICHIGAN i

THERAPEUTIC

APPROACH

TO

CANCER

/

467

an acid pattern pain and with this restriction, pain was efficiently controlled. We used the effect upon pain as a criterion, and we discontinued treatment in any case in which fatty acids induced or increased pain. Subsequently, along with the effect upon pain, we used urinary pH and specific gravity as criteria for treatment with fatty acids. A persistent high urinary pH and a low specific gravity were indications for the use of these substances. In addition to the control of severe pain, interesting objective changes occurred. Unfortunately, most of them were only temporary. The following two examples taken from a group of 15 similar cases are illustra¬ tive. L. B., 66 years old, had cancer of the right lung for which he had re¬ ceived only symptomatic treatment. For more than a month the patient had complained of pain in the right chest, with increasing breathing difficulty. Chest X-ray examination revealed a tumor of the right lung extending from the mediastinum into the medium lobe. A diagnosis of bronchogenic cancer was made. Subsequent X-ray examinations showed rapid growth with sev¬ eral tumors in the upper lobe and in the left lung. The general condition was rapidly and progressively deteriorating, the dyspnea and pain increas¬ ing. Two months after first symptoms, the patient was bedridden. When the patient came under our care a few weeks later, he was dyspneic, slightly cyanotic, had persistent cough, was extremely fatigued and in almost continuous pain. By this time, we had started to use urinary specific gravity and pH as criteria for the recognition of the oflfbalance present. Because of low specific gravity and high urinary pH, the patient was given oral treatment with cod liver oil fatty acids. Gelatinous capsules containing 0.25 gm. of the fatty acid mixture were used in a starting dose of 0.5 gm. a day, and were increased progressively to 1.5 gm. a day. The patient made an impressive gain in a few days of treatment. The pain dis¬ appeared entirely, as did the dyspnea. The cough also almost disappeared in a few days, and in two weeks the patient was able to get out of bed. The improvement continued, and in less than two months, the patient was even able to go horse-back riding. Radiologically, the tumors also showed pro¬ gressive regression. We continued the treatment with a relatively high dosage—2 grams of cod liver oil fatty acids daily—for a total of two months, with evidence of continued improvement. Then, suddenly, symp¬ toms of pulmonary congestion became apparent and the general condition rapidly became worse. Urine analyses now showed a high specific gravity and a low pH. In spite of discontinuing the medication, the patient was back in bed with increasing dyspnea. He died two weeks later with symp¬ toms of pulmonary edema.

Digitized bv

Google

original irom

UNIVERSITY OF MICHIGAN

468

/

RESEARCH

IN

P H Y S I O P A THOLOOY

Mrs. D. A., 68 years old, had a cancer of the left breast for which she had undergone a radical mastectomy four years previously. Pathological examination of the lesion had shown an adenocarcinoma Grade IV, with ganglionar involvement. When the patient came under our care she was bedridden with a diagnosis of multiple bone metastases. Radiological ex¬ amination showed multiple osteolytic lesions in the pelvis, femur, lower spine, ribs and skull. We instituted treatment with cod liver oily fatty acids in gelatine capsules. The dose was progressively increased, by 0.25 gm. increments, until it reached 3 grams a day. Ortho-phosphoric acid was added orally in doses of Va

cc.

of a 50% solution given in water in order

to control the pain which appeared after administration of the capsules and was of an alkaline pattern. Improvement began in a few days and continued so satisfactorily that in less than six weeks the patient was up and about. Five months later, with bone lesions healed, the patient went home. I saw her in 1941, almost two and a half years later, during which time no treat¬ ment had been given. When examined at that time, she appeared in excel¬ lent condition. Subsequently, because of the war, I lost contact with her. The increase of pain, and especially the frequent appearance of pain of an alkaline pattern after extended treatment, considerably limited the use of these cod liver oil fatty acid preparations. Furthermore, an incon¬ sistency in objective changes was seen even when administration was guided by the acid or alkaline character of the pain. In most patients, favorable objective changes were only temporary. During this research, we observed a very favorable response in some cases of hemorrhage, especially of the long-term oozing type, treated with these preparations. Bleeding usually stopped after one injection of 1 cc. of a 10% solution of unsaturated members of cod liver oil fatty acids. We still use this preparation for this purpose, as mentioned previously. Among the group of lipids opposed to fatty acids, we first used choles¬ terol with the intention of trying to influence pain having an alkaline pat¬ tern. The effect was much less impressive than that obtained with fatty acids in pain of acid pattern. In some cases, objective changes also were observed although they were less frequent and less profound than those seen with the fatty acid preparations. Cholesterol alone never produced total clinical disappearance of tumors. Acid Lipidic Fractions and Unsaponifiable The development of the concept of dualistic pathogenic intervention of two groups of lipids led us to a treatment employing these two types of lipid constituents of the body chosen according to the character of the

Google

original irom

UNIVERSITY OF MICHIGAN

THERAPEUTIC

APPROACH

TO

CANCER

/

469

manifestations. We obtained from different organic sources the insaponifiable fraction as well as the acid lipid fraction. Human placenta was widely employed. The two preparations, acid lipid and insaponifiable fraction, were used until 1943 on about 200 patients (in France, and Mexico). Some good subjective and objective results were observed. The subjective changes were most impressive. Frequently, an injection of only 1 cc. of the human placenta acid lipid preparation (5% in oil) controlled pain in a few minutes, with relief lasting for hours or sometimes even days. With the same preparation, alkaline pain increased after only a few minutes and sometimes became unbearable. In cases treated with placenta acid prepa¬ ration, using acid pain pattern as a criterion, we observed some significant objective changes. Mrs. B. B., 54 years old, with a papillary adenocarcinoma of the ovary and multiple peritoneal metastases found during exploratory laparotomy, had rapidly reproducing ascites. The patient required repeated paracenteses at short intervals. In the month just prior to coming under our care, it had been necessary to tap her once a week or even every five days. Treatment with acid lipids of placenta was instituted, with daily injections, first of 1 cc. and then of 2 cc. of the 5% oil solution. In less than two weeks, the pain was controlled and much less fluid accumulated. The patient had two more paracenteses at two and three week intervals, after which fluid no longer was a problem. The multiple tumor masses, which were very easily felt through the skin after each paracentesis, were seen to decrease rapidly and disappeared in about two and a half months of treatment. After four months, treatment was discontinued and no recurrence was seen during the three years we followed this patient. We saw Mrs. L. S. N., 73 years old, in 1942 in a subcomatous state, with deep jaundice and with a history of primary tumor of the stomach and multiple big metastatic lesions of the liver. Her condition, which had started a few months earlier, was getting rapidly worse. When we examined her, the liver was occupying the abdomen until the pubis, and practically each of the individual metastatic tumors present at the surface of the liver was easily palpable through the thin abdominal wall. Guided by the urine analyses—with a high pH and a low oxireduction index—we started with a treatment with 10% solution in oil of a human placenta lipoacid preparation. The doses were increased according to the analyses until they reached 3 injections daily of 2 cc. each. The patient improved, and in less than a week she was conscious again. Her condition continued to improve for more than a month when a rapid change for the worse took place. As the analyses at this time showed the opposite offbal-

ed b> Google

UNIVERSITY OF MICHIGAN

470

/

RESEARCH

IN

P H Y S I O P A T H OL O O Y

ance present, the treatment was changed. In addition to infusions with glu¬ cose and saline, glycerol in a dose of 8 drops daily with 20 drops of coramine was given. Again the response was impressively good. The general condition improved rapidly and in less than a month, the patient was out of bed and started to take care of her home. By this time, the jaundice had almost completely disappeared, although the liver remained almost of the same dimension. The patient continued to take glycerol for more than 6 months, leading an absolutely normal life. It took almost one year for the liver to come back to normal dimensions. The patient remained in perfect health for the next 9 years. Several coronary occlusions led to her death at the age of 83, from a myocardial infarction. She showed no objective or subjective signs of recurrence of either her stomach or liver condition. Unfortunately, uncontrollable changes toward rapid tumor growth ulti¬ mately occurred in most cases treated with placenta acid lipids despite favorable objective changes at the beginning of treatment. Clinical use of the insaponifiable fraction preparations supported obser¬ vations made in animals, indicating the importance of other factors for obtaining favorable changes in tumors. With the insaponifiable fractions of placenta, marked clinical effects could be obtained only when the condition of the patient permitted the treatment to be continued for a long time. Temporary regression or even clinical disappearance was effected in several cases, only to have the tumors start growing again, this time beyond control by the medication. Even at this point, it was obvious that favorable influ¬ ence with these two antagonistic groups of lipids was dependent on using the lipid which corresponded to the pattern present. It became increasingly evident that changes in the pattern occurred during treatment. Administra¬ tion of acid lipidic and insaponifiable fractions induced unfavorable re¬ sponses in patients with tumors in which a predominance of the same lipids was indicated by analyses. Pain increased and unfavorable changes oc¬ curred in the evolution of the disease. For example: Mrs. A. D., a 42-year-old woman, operated on for an adenocarcinoma of the breast 18 months prior to coming under our care, presented a few skin lesions near the operation scar. Radiological study revealed a few small osteolytic lesions in two ribs, and one in the skull. The analytical data showed low urinary pH, high specific gravity and high chloride index, in¬ dicating an offbalance which we attributed to predominance of fatty acids. Treatment with 2 injections daily of 1 cc. of a 5% oily solution of the in¬ saponifiable fraction of placenta was started. This was later increased to 2 cc. twice a day. The patient left the city for a summer vacation and took the medication with her. Disregarding our instructions that treatment must

Google

UNIVERSITY OF MICHIGAN

THERAPEUTIC

APPROACH

TO

CANCER

/

471

be guided by further analysis, she continued it without interruption for four weeks, despite a rapid change in her condition and a constant increase in the pain after each injection. When we saw her again a month later, all the analyses had changed markedly, indicating the appearance of an opposite offbalance. Clinically, the condition also had changed. The skin was ex¬ tensively involved in the vicinity of the operative scar and multiple, rapidly growing metastases were seen all over. Radiological study showed extensive new lesions in many bones. The condition had progressed in one month in a manner never seen before in any patient and we had to relate it to con¬ tinued use of medication after a change in the offbalance. This change was similar to that seen in animals with massive administration of the insaponifiable lipidic preparation. Switching to placenta acid lipid preparations quickly changed the evolution of the condition in this patient. Pain was controlled and for three months the condition seemed arrested. In spite of treatment, however, it started to evolve rapidly again after that and the patient died five months following her return from vacation. Similar deleterious effects were seen with acid lipid preparations ob¬ tained from organs when their administration apparently was at variance with the pattern present. W. S., 56 years old, had a carcinoma of the cheek mucous membrane which led to wide perforation. Biopsy of the edges of the ulceration showed squamous cancerous tissue. Based upon the urine analysis, which indicated low specific gravity and high pH, treatment consisted of two daily injections of 1 cc. of the acid lipid fraction of placenta in a 5% solution in oil. As the patient was treated on an ambulatory basis, he was advised to see us in a few days. He continued the treatment without any control for two weeks. When next seen, a marked gelatinous edema of the tissues sur¬ rounding the ulceration was found and the patient complained of severe pain. Biopsy at this time revealed, in addition to interstitial edema, a high vacuolization of the cancerous cells which had not been seen in the biopsy done the day prior to beginning treatment. The pain became unbearable a few minutes after each injection. These local changes were accompanied by a marked deterioration of the general condition, the patient complaining of a sensation of weakness. The unfavorable changes which occurred in only two weeks were very impressive. Favorable results were obtained even in terminal cases with these frac¬ tion preparations. In some cases, arrest or disappearance of tumors was noted. In most cases, however, these effects were only temporary. After being arrested for months or even years by these lipid preparations, some tumors began to grow and to become painful and could not be as readily

Google

UNIVERSITY OF MICHIGAN

472

/

RESEARCH

IN

PHYSIOPATHOLOGY

controlled again by the same preparation. In a small number of patients, about 3% of the group of 200 treated with these preparations, the favor¬ able results could be maintained over a number of years. Even with the relatively strict guidance of therapy by the analyses available at the time, results were not always favorable. We attributed this both to the agents used for therapy and the criteria employed for recog¬ nition of offbalances. For a long time, research was devoted to developing means to permit better recognition of offbalances and to ascertain the value of the various analyses used as criteria for the conduct of treatment. Each new urine or blood test was investigated as a criterion for the group of lipids to be administered. This led to better results in controlling pain, improving the general condition and even in objective changes in tumors. However, the temporary character of the effects obtained with lipids derived from normal organs appeared more and more evident in long-term appraisal of results. We changed from human placenta to other sources for both acid and insaponifiable fractions. We prepared and used lipids from different organs of cow, pig, fish, and chicken. We also used mollusks, chicken embryos, molds and even microbes, as well as milk and eggs as source for these lipids. In one group of investigations, we even tried to use lipids of the organ from which the tumor derived. Most of these preparations satisfactorily controlled pain, and in some cases, good results were seen in the growth of tumors. The following observation concerns a case treated with the lipoacids of human blood. A. M., a 56-year-old man, was referred to us by his physician with a diagnosis of cancer of the rectum. Difficulty in defecation, mucosanguinolent discharges, and pain in the rectal region had been increasing in the three months prior to the diagnosis. Examination had revealed a tumor of a cauliflower type, starting at about 4 cm. from the anal orifice and almost entirely filling the rectal ampulla. A biopsy had shown it to be an adeno¬ carcinoma, Grade III. The patient had refused surgical intervention be¬ cause, years before, a minor operation on his right hand had led to local infection followed by amputation of the hand. At the time he was referred to us, his main complaints were pain in the rectum, radiating to the left leg, and tenesmus with frequent mucosanguinolent discharges. We employed daily injections of 1 cc. of a 5% oily solution of the acid Iipidic fraction obtained from human blood. The treat¬ ment was continued for six weeks, the injection being given daily during the first two weeks and twice a week thereafter. After one week, the pain and tenesmus disappeared and there was a decrease in the mucosanguinol-

Digitized by

Google

UNIVERSITY OF MICHIGAN

THERAPEUTIC

APPROACH

TO

CANCER

/

473

ent discharge. There was also an obvious decrease in the size of the tumor. In less than a month the tumor regressed to one-fourth its original size; in six weeks, digital and proctoscopic examination showed no clinical tumor. A whitish scar could be observed in the posterior wall of the rectum. Thereafter, the condition of the patient was followed indirectly through reports from his physician. There was no tumor recurrence in spite of the fact that he received no further treatment. He died six years later from an acute paratyphoid infection.* Our clinical experience provided ample evidence that the preparations rich in polyunsaturated fatty acids would influence pain as well as the growth and evolution of human cancers. Using the same amounts of polyethenic fatty acids prepared from various sources, no differences in effects could be noted. The effect upon tumors in all instances was relatively limited. Our next effort was to try fatty acids unlike those found in the organ¬ ism. They included norbixine—the monomethyl ester of the bicarboxylic acid, bixine—which we used in a group of patients between 1938 and 1940. With urinary specific gravity and pH as criteria, daily doses of from 1 mgr. to 100 mgr. were administered to 30 preterminal and terminal pa¬ tients with patterns corresponding to predominance of sterols. Even with small doses, the changes toward a predominance of fatty acids were im¬ pressive. Superficial, massive tumors were often seen to melt away within a few days, usually leaving ulceration in their place. This rapid change of a massive tumor into an ulcerated one, however, usually was followed by a manifest deterioration of the general condition. With this preparation, once the offbalance was changed from the original to the opposite type, attempts to control the new offbalance were usually unsuccessful. This led us to discontinue its use at this time in spite of the rapid and intensive changes it induced in tumors. Groups of Agents Parallel to these researches on fatty acids, the use of agents with posi¬ tive polar groups also underwent changes. As previously mentioned, it appeared increasingly clear that no single agent could be effective in itself if an offbalance corresponding to predominance of fatty acids was present. Quite early in this research it could be observed that the simultaneous use of two agents from the same group appeared to be a better procedure than using either agent alone. In a limited number of patients treated with single agents, without impressive clinical changes, better effects were obtained when combinations were tried. Although it was difficult to ascertain in

Digitize

d by Google

I i U I I | ' i I

UNIVERSITY OF

CHIGAN

474

/

RESEARCH

IN

P HY S IOP ATH OLOO Y

individual cases that favorable effects were due exclusively to change in medication, the following cases are interesting. A. Ch., a 53-year-old woman, had a radical mastectomy for an adeno¬ carcinoma of the right breast with axillar and supra clavicular ganglionar involvement. Almost two years later—during the three months immediately prior to the time we first saw her—she showed rapidly developing multiple metastases for which only symptomatic treatment was applied. Along with multiple bone metastases, and a recent pathological fracture of the inferior third of the right femur, there were liver metastases and a right pleural effusion for which she had been tapped three times. When she came under our care, she complained especially of pain in the lower back caused by lumbar and sacrum metastases. Her condition was considered terminal so that the surgeon did not think it advisable even to apply traction for the fracture of the femur. It was under these conditions that we started to treat her with two injections a day of 1 cc. of a 5% solution in oil of the insaponifiable fraction of human placenta. Except for the unexpected sur¬ vival of the patient, no apparent change was seen after two weeks of treat¬ ment. The pain, pleural effusion and general condition remained the same. The treatment was changed to 5 drops of glycerol three times a day, and the dosage was progressively increased to 15 drops of glycerol t.i.d. After ten days without change, Coramine in doses of 15 drops was given when necessary to control the typical alkaline pain. After another week there was still no change. The pain remained almost the same, except for a decrease in intensity immediately following administration of Coramine. When all three substances were given concomitantly—the insaponifiable fraction by injection and glycerol and coramine orally—the situation changed impressively. Within a few hours, pain disappeared completely, and within one week other manifestations had totally changed. The pleural effusion, for which the patient had been tapped regularly each week or every 6 days, disappeared. The fracture which, until then, had appeared entirely inactive, showed a consolidation so rapid that in less than two weeks a solid callus was present. In three weeks the patient was out of bed on crutches. X-ray pictures taken two months after the change in medica¬ tion showed most of the osteolytic lesions replaced by new bone tissue and the fracture replaced by an abnormally solid callus. There was no fluid in the pleura. All treatment, except the glycerol, was discontinued after an¬ other three months when, at the start of the war, the patient left Paris. We heard that she continued in good health wihout further treatment for three more years, at the end of which time she developed a recurrence, with liver metastases, and died shortly thereafter.

Google

UNIVERSITY OF MICHIGAN

THERAPEUTIC

APPROACH

TO

CANCER

/

475

M. R., a 58-year old woman, the wife of a professor of gynecology, had an ulceration of the cervix two years before coming under our care. Biopsy had revealed.squamous carcinoma, Grade III. After local treatment with radium, she underwent total hysterectomy. Six months before we saw her, she developed multiple abdominal metastases for which only symp¬ tomatic treatment was prescribed. When she came under our care, she had a distended abdomen in which masses of various dimensions were easily palpable. Besides several large tumors, two of them about 15-20 cm. in diameter, there were many smaller ones which gave the distended abdomen a very irregular appearance. The abdominal pain, her generally poor con¬ dition, as well as severe edema of the legs, kept the patient bedridden. She showed a high urinary specific gravity and low pH, and treatment consist¬ ing of a daily injection of 2 cc. of a 2.5% solution of cholesterol in oil was prescribed. When no subjective or objective changes were seen in three weeks, the treatment was changed to 10 drops of glycerol orally, three times a day, for another three weeks. There was still no obvious change. After another three week period, this time without treatment, during which her general condition deteriorated, mixed treatment with cholesterol and glycerol was started. The patient now made a sudden remarkable re¬ covery. The edema of the legs disappeared rapidly and in less than a month the tumors were no longer palpable. The abdomen, however, continued to be distended, but instead of the previous irregularity with multiple welldelineated tumors, a single huge mass was recognized. It filled practically the entire abdomen. We made the diagnosis of a large ovarian cyst which had probably been present before but had been obscured by the multiple tumors. The patient was operated on three months later and the cyst was removed. Not only were no tumors found in the abdomen, but there were no adhesions which the surgeon had feared. White patches were seen at the sites previously occupied by the tumors. There were no recurrences during several years of follow-up, after which we lost track of the patient. Similar results were obtained during the following years, indicating the value of mixed therapy. We made it our standard clinical treatment except when the pharmacodynamic effect of a specific agent was being investigated. As an example of the objective changes obtained through mixed treat¬ ment for type D offbalance, we give an abbreviated form of the following observation. Miss S., 39 years of age, came under our care with bone metastases from an adenocarcinoma of the breast, for which she had a radical mastectomy 1 Vi years previously. At admission in very severe pain, besides other multiple bone metastases, she showed especially a marked destruction

Google

UNIVERSITY OF MICHIGAN

476

/

RESEARCH

IN

PHYSIOPATHOLOGY

Fio. 154. Aricriopostcrior view of the chest of patient S at time of admission show¬ ing an osteolytic process in the 6th and 9th left ribs.

Fig. 155. Arteriopostcrior view of the chest of patient 5 months later, with the appearance of the new hones replacing the part of the ribs previously destroyed.

Digitized by

Google

Original from UNIVERSITY OF MICHIGAN

THERAPEUTIC

APPROACH

TO

CANCER

/

477

of the 6th and 9th left ribs. (Fig. 154) The analyses showed an offbalance type D and consequently she was treated with butanol and glycerol. The patient showed rapid changes not only in her subjective feeling, but also objectively. Fig. 155 shows the rib osteolytic lesions healed and the missing bone replaced by new bone. In general, however, in spite of some favorable cases, the results were not satisfactory. Even in patients in whom tumors regressed and disap¬ peared, recurrences were seen anywhere from a few months to several years after discontinuation of treatment. By prolonging treatment over a period of years, the period of improvement was lengthened in some cases. Still, all too often the response to treatment was only temporary.

Mercaptans Other substances with lipoidic character but with a polar group differ¬ ent from the carboxyl were tested. Mercaptans, as lipoids with a thiolic negative polar group, were used. In 1942, we started to study the thera¬ peutic effect of ethyl mercaptan injected intramuscularly, in a 10% solution in oil. (326) Use of ethyl mercaptan had to be limited to subjects with an offbalance corresponding to a predominance of sterols. Although only a few patients were treated because of the offensive odor, the results were satisfactory as indicated by the following case histories. F. C.—This patient, at the age of 66, had a small carcinoma of the tip of the tongue resected at Columbia Presbyterian Hospital on May 6, 1941. At the same time, a second carcinoma of the left lateral border of the tongue was found infiltrating into the deeper portions. This lesion was treated with radium needles with a total dose of 2500 mg. hours. In Septem¬ ber 1941, a prophylactic left radical neck dissection was performed. The patient was well for 8 months thereafter, and then began to experience soreness in the region of the scar on the lateral side of the tongue. In August 1942, 16 months after the tumor had been irradiated, the patient came under our care. At the juncture of the anterior and middle third of the left lateral border of the tongue, there was an induration of 2/1 cm. in dimension with an ulceration of 1/0.5 cm. covered by necrotic tissue. The indurated base was especially developed anteriorly to the ulcer¬ ated lesion. There was no evidence of recurrence at the scar of the tip of the tongue nor at the left side of the neck. The latter lesion was very tender. A Wassermann analysis was negative. Biopsy of the edge of the ulcerated tumor revealed squamous cell epithelioma. The patient was treated with placental acid lipid fraction for the first

Digitized by

Google

UNIVERSITY OF MICHIGAN

478

/

RESEARCH

IN

P H Y SI OP A TH OL OOY

week without any subjective or objective change. The treatment was changed and the patient received 1 cc. of a 10% solution of ethyl mer¬ captan in oil intramuscularly, three times a day. The dose was increased after three days to 2 cc., three times a day. By the end of one week under this treatment, pain had disappeared, although there was still some burn¬ ing sensation. The appearance of the lesion was unchanged. The treatment was continued. By the end of the second week, the edema was reduced, and after another week of the same treatment, the induration was gone. After one month of treatment with ethyl mercaptan, epithelization of the lesion was noted. The treatment was discontinued. The lesion appeared completely healed, without induration, burning sensation or pain, less than a week later. The patient has remained without treatment since, and there has been no recurrence in the last 18 years. Three years ago, the patient had a basal carcinoma of the skin of the nose, which responded well to local treatment with radium in Mexico. Mrs. L. F.—In June 1942, the patient then 50 years old, observed an induration on the right border of her tongue. Biopsy revealed a squamous cell carcinoma. After the biopsy, the lesion progressed so rapidly that it was judged inoperable. Without having received any other treatment, the patient came under our care in August 1942. At that time, the tumor had involved the right half of the tongue and multiple submaxillary and neck nodes, the biggest being 2 cm. in diameter. The lesion was extremely pain¬ ful. Urine analyses showed low specific gravity and high pH and the patient was treated with 10% ethyl mercaptan in vegetable oil. We started with three Vi cc. injections daily. The dose was progressively increased until it reached 6 cc. daily. The pain disappeared entirely in less than a week. Treatment was continued for only 3 Vi weeks at which time there was a marked improvement in the tongue lesion and lymph nodes. Except for an inflammatory reaction at the site of injection, no side effects were seen. A month after the start of treatment, the lesions had completely disap¬ peared. No treatment has been given since. The patient is still well today, free of recurrence, 18 years after treatment with ethyl mercaptan. H. A.—In May 1942, at the age of 52, the patient developed hema¬ turia, pyuria and tenesmus. In June 1942 an infiltrating tumor of the right side of the trigone was revealed by cystoscopy and cystogram. The patient came under our care at the end of August 1942. Having high urinary specific gravity, he was treated first with insaponifiable fraction of placenta, receiving 1 cc. of a 5% preparation in oil three times a day. Hematuria and the other symptoms increased under the treatment which was then changed to ethyl mercaptan, 10% solution in oil, starting with Vi cc. three

Google

UNIVERSITY OF MICHIGAN

THERAPEUTIC

APPROACH

TO

CANCER

/

479

times a day. The dose was progressively increased to 3 cc., three times a day by the tenth day. Hematuria decreased in the first 48 hours and ceased completely on the fourth day. Other symptoms disappeared. The treatment was continued with this dose for another 2V4 weeks. Disappearance of the tumor was seen in follow-up cystograms. Without further treatment, the patient remained well until the beginning of 1955, 12Vi years later, when a recurrence of the tumor of the bladder was noted. Being in Mexico, he did not receive treatment by this method and died from generalized car¬ cinomatosis after 9 months. (Figs. 156 and 157)

Fio. 156. Cystogram of patient H.A. before treatment.

Similar favorable results were obtained for other patients with patterns corresponding to sterol predominance. We treated only three patients with patterns indicating fatty acid predominance. The use of ethyl mercaptan in these cases caused an exacerbation of symptoms and rapid deterioration of the general condition. The odor of ethyl mercaptan was so offensive that its use posed in¬ surmountable problems. Patients were forced to be social recluses and it was practically impossible to get nurses to administer the injections because of persistence of the odor on skin and clothes. We had many complaints that the odor of the medication polluted the atmosphere of a large area for

Original from Digitized by

UNIVERSITY OF MICHIGAN

480

/

RESEARCH

IN

PHYSIOPATHOLOGY

a long time. Obliged to discontinue its use, we sought other preparations containing thiol groups or bivalent sulfur that we hoped would have similar biological effects. We investigated a large number of such substances in animals. Only a few were extensively studied in patients. Of the homologous series of ali¬ phatic mercaptans, we utilized propyl, butyl and amyl mercaptans. These offered no advantage over ethyl mercaptan, being less active but hardly less offensive in odor.

Flo. 157. Cyslogram of patient H.A., after treatment with ethyl mercaptan.

Hexyl mercaptan was the first of the series that had a more bearable odor but it was definitely less active. Although objective changes in cancer were observed with its use, the tumors did not disappear as they did in some cases treated with ethyl mercaptan, and many favorable responses were only temporary. Of the higher mercaptans, dodecyl and hexadecyl were most extensively studied. While their odor was far less objectionable, they produced less favorable results than the lower homologues. Much larger doses were re¬ quired to influence pain, and even then the effects were reduced and tem-

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

THERAPEUTIC

APPROACH

TO

CANCER

/

481

porary. The striking results obtained with ethyl mercaptan could not be duplicated with any of the higher homologues. For this reason, we re¬ luctantly abandoned the use of mercaptans. Sulfurized Oil During the years that followed, we tried to achieve results similar to those obtained with ethyl mercaptan by using other agents with bivalent sulfur. The one most commonly used was the so-called “sulfurized oil” containing fatty acid hydropersulfides, whose pharmacological character¬ istics have been discussed previously. Sulfurized oil’s effects on pain and systemic manifestations were less impressive than those of the mercaptans but better than those of unsaturated fatty acids and their derivatives. In several cases, tumor disappearance was actually observed. Generally the clinical results were neither as consistent nor as persistent as with the mercaptans. With the use of this product alone, however, long-term fa¬ vorable responses were the exception. For example: Mr. I. G.—White male, was operated on at Maimonides Hospital in January 1950 at the age of 56. A pyloric mass was found and a subtotal gastrectomy was performed. Diagnosis of adenocarcinoma of the stomach was made. Microscopic examination showed a large area of replacement of gastric mucosa by atypical glands, with a great mass of abnormal cells in¬ vading the submucosa. These cells extended into the first part of the duo¬ denum. There were post-operative complications with abscess formations in the wound, which were incised and drained. With new complaints of pain in the upper abdomen, and rapid loss of weight, the patient was ad¬ mitted to Monticello Hospital in July 1950, and to Kings County Hospital twelve days later. He was then transferred to a nursing home with a diag¬ nosis of terminal cancer with recurrent tumor in the upper abdomen and metastases to the chest. He remained at the nursing home for seven weeks. In September, he came under our care. At this time, he had lost 39 lbs., and complained of extreme weakness, pain in the lower chest and upper abdominal region, and cough with hemoptoic sputum. The pain was only slightly relieved by narcotics and the general condition of the patient was considered very poor. A large mass was found occupying the entire upper abdomen; X-ray examination of the chest showed masses in the right lung. No fluid was obtained from several chest punctures. Based on the urinary analyses, the patient was treated with a prepara¬ tion of hydro-persulfide. The response was excellent. Not only was his pain rapidly relieved but the mass in the abdomen progressively decreased in

Digitized

Google

unginai Trom

UNIVERSITY OF MICHIGAN

482

/

RESEARCH

IN

PHYSIOPATHOLOOY

size. Evidence of lung involvement slowly disappeared in X-ray studies. After November 1950, he continued the treatment at home for over 13 months after which he resumed his old job as a millinery cutter. He had gained 55 lbs. since beginning treatment For the past IVi years, he has worked without interruption and there has been no clinical evidence of malignancy. The extreme condition under which the patient came into our care can explain the length of time needed for general recovery and his inability, despite disappearance of the tumoral masses within a few months, to resume his job for more than a year. Thiosulfates We also utilized sodium thiosulfate in many patients where symptoms such as pain, vertigo, itching, etc., could be related to a local acid pattern. In these specific cases, the results were generally satisfactory. Sodium thiosulfate was administered either orally in drops of a 10% solution in water, or parenterally in a 4% solution in water. Intramuscular and sub¬ cutaneous injections were well tolerated even when doses were as high as 10 cc. Doses as small as lOmgs. were observed to influence symptoms in certain patients. However, in some cases it was necessary to give as much as 5 gr. of the substance—125 cc. of the parenteral solution—in 24 hours to obtain any effect. In these cases there were no apparent side effects even when this dosage was continued for many days. Effects upon tumors with the use of thiosulfate alone were seen in several cases but the treatment did not produce complete disappearance and results usually were only tempo¬ rary. The use of sulfurized oil in conjunction with sodium thiosulfate has been tested in a sufficient number of cases (more than 75) to enable us to recognize that the combination produces changes in pain and systemic analysis, as well as reduction in the size of tumors, especially when given in adequate amounts over a long enough period of time. In several cases, tumors disappeared for many years following this treatment. The following are illustrative cases: G. M.—In March 1944, this patient had an ulceration of the cervix. Biopsy showed squamous cell epithelioma, Grade III. A total hysterectomy was performed. She was treated with 3,600 mg. hours of radium in and around the cervix in April 1944. Five months later, there was evidence of local recurrence and the patient was given 1800 r. of deep X-ray therapy. In July 1945, examination revealed no evidence of disease. On October 28, 1945, the patient was examined at the Scott and White clinic in Temple, Texas, and a diagnosis of extensive metastatic carcinoma of the para-

Google

UNIVERSITY OF MICHIGAN

THERAPEUTIC

APPROACH

TO

CANCER

/

483

metria was made and further deep X-ray therapy was advised. The patient refused this. She came under our care in November 1945. She was extremely weak and showed evidence of considerable weight loss, weighing only 86 lbs. Hematuria and dysuria were the principal complaints. Multiple large tumor masses were palpable in the pelvis and extended into the abdomen above the umbilicus. The largest mass palpable, about the size of a big grape¬ fruit, was in the right lower quadrant. The tumor was found to have in¬ vaded the bladder, too. The treatment with which we started, t.i.d. intramuscular injections of 1 cc. of placenta fatty acids, 10% in oil, was changed after one week, in view of the preterminal condition of the patient. A hydropersulfide prepa¬ ration containing 1% sulfur, and sodium thiosulfate 10% was administered orally. We started with a dose of Va

cc.

three times daily of hydropersulfide

and Vi cc. thiosulfate and increased it progressively, with amelioration of the general condition and disappearance of the hematuria. After a month, the dosage reached 3 cc. of the first and 9 cc. of the latter preparation daily. Under this treatment, the patient continuously gained strength and weight. The hematuria did not reappear. In May 1946, she was admitted to the University of Chicago clinic. A large fixed, firm, irregular tumor mass was still present in the lower abdo¬ men rising from the pelvis to the umbilicus. Although her general condition had improved, the patient again had urinary frequency and urgency, and cystoscopy revealed a severe cystitis and several small stones in the bladder. An intravenous pyelogram showed a right hydro-nephrosis. The treatment with hydropersulfide and sodium thiosulfate was con¬ tinued for 4 months in Chicago during which time the abdominal mass became smaller, softer, less fixed and was no longer tender. By August 1946, her weight was 136 lbs., a gain of 50 lbs. since start of treatment. The treatment was continued during 1947, although abdominal examina¬ tion did not reveal any palpable masses. On rectal examination, however, the pelvis appeared to be frozen but no definite mass was felt. Cystoscopy showed severe cystitis, bladder calculi and a distorted bladder. Although she passed several stones and gravel, her urinary symptoms persisted. In December 1948, an attempt was made in Texas to remove a bladder calculus transuretherally after lithotrity. The bladder was perforated during this procedure and a recto-vasical fistula resulted. The patient’s local physi¬ cian in Texas believed that the patient was terminal, but we insisted upon This was done, and the surgeon reported that there was no evidence of any a colostomy to divert the fecal stream as an immediate first procedure.

Google

UNIVERSITY OF MICHIGAN

484

RESEARCH

IN

PHYSIOPATHOLOGY

pelvic or abdominal masses. The patient made a slow recovery. According to reports to this date, 16 years after start of treatment, no recurrence has been noted. Recently the colostomy was closed, the patient being in good condition. Mrs. M. L.—In November 1941, at the age of 40, the patient had a left oophorectomy for a multi-loculated ovarian tumor with ascites and peritoneal implants. The pathological finding was papillary cyst adenocar¬ cinoma of the left ovary. Without any other treatment, she remained free

Fic. 158. Photomicrograph of lymph node from Case E.H. showing metastatic adeno¬ carcinoma Gr III (400 x).

of symptoms until the beginning of 1945, when she started to complain of abdominal discomfort in the lower left quadrant. A mass was found at the site of operation. Growth was noted in further examinations. The pa¬ tient had no treatment until December 1945, when she came under our care. On examination, a tumor of 11/6 cm. with limited mobility was found. No abdominal fluid was present at this time. She was started on amylmercaptan in doses increasing to 6 cc. daily of a 10% solution in oil. The treatment was discontinued after a week because of the odor. No manifest changes could be seen. A preparation of hydropersulfide contain¬ ing 1% sulfur, in a dose of l cc. three times a day orally, was used. The mass in the left parameter disappeared entirely in about 2 months. She

Google

UNIVERSITY OF f

HIGAN

THERAPEUTIC

APPROACH

TO

CANCER

/

485

continued with the same medication for another 14 months. There has been no recurrence to date. Mrs. E. H.—In April 1947, at the age of 46, this patient had a right radical mastectomy. The pathological diagnosis was adenocarcinoma, Grade III, with metastases to axillary lymph nodes. (Fig. 158) A course of post-operative irradiation was administered. Menses had been interrupted 8 years before by a total hysterectomy and bilateral salpingo-oophorectomy.

Pig. 159. Anteroposterior view of chest in Case E.H. at conclusion of testosterone und deep X-ray therapy to spine, showing destruction of medial '/j of left clavicle and metastatic rib lesions.

The patient was free of symptoms until July 1948, when she began to complain of back pain and difficulty in walking. X-ray examination re¬ vealed osteolytic metastatic lesions in the medial third of the left clavicle, pelvis, thoracic and lumbar vertebrae, with collapse of the ninth thoracic and third lumbar vertebrae. She was hospitalized and deep X-ray therapy was applied to the thoracic and lumbar vertebral regions and the right hip. 1800 r. being delivered to each of the three fields. A total of 600 mgm. of testosterone propionate was also administered in four weeks (50 mgm. three

Original from Digitized by

UNIVERSITY OF MICHIGAN

486

/

RESEARCH

IN

PHYSIOPATHOLOGY

times a week). Clinically, there was improvement and the patient was able to walk with the aid of a back brace and cane upon discharge. X-ray exam¬ ination on August 22, 1948, at the conclusion of this period of therapy, revealed continued spread of osteolytic lesions, involving the bodies of the lower cervical, lower thoracic and lumbar vertebrae and pelvis. Numerous lesions were observed in the left ribs and in the upper thirds of both femurs. There was further destruction of the left clavicle. (Fig. 159)

Fig. 160. Anteroposterior view of chest in Case E.H. two months after stopping testosterone and X-ray therapy, showing further involvement of medial Vy of left clavicle.

After discharge, the patient did not receive any further X-ray therapy or testosterone. The clinical improvement lasted for only a short time, the back pain and difficulty in walking recurring within a few weeks. Radiographic examination at the end of October revealed further increase of the previously described lesions, with new areas of involvement. (Fig. 160) The patient received several injections of an unknown medication at home but her condition continued to grow worse. Pain was more severe, and required increasing amounts of narcotics. The patient was confined to bed and there was evidence of increasing nerve involvement, culminating.

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

THERAPEUTIC

APPROACH

TO

CANCER

/

487

by the end of November, in paralysis of both lower limbs with loss of sensation below the level of the ninth thoracic vertebrae. There was no bladder or rectal dysfunction. The patient came under our care in this condition on December 21, 1948. Pain was so severe that a body cast appeared indicated, but the or¬ thopedic consultant considered the patient’s condition too far advanced to warrant this. The urinary pH was alkaline.

Fig. 161. Lateral view of thoracic spine in Case E.H. at time of admission, showing extensive metastatic involvement of vertebrae with collapse of fifth and ninth verte¬ brae.

A hydropersulfide preparation with 0.5% sulfur was administered in doses ranging from several drops by mouth to 1 cc. twice a day intramuscu¬ larly. Sodium thiosulfate in a 10% aqueous solution was given at the same time by mouth, and after a few weeks a 4% solution administered intra¬ muscularly was substituted and was given in increasing doses up to as much as 11 cc. every few hours. For a short period, colloidal sulfur was administered in doses of 100 mgm. orally every three hours. During the first few weeks, with small oral doses of sulfur in oil and sodium thiosulfate, there was no evidence of improvement. 2 cc. doses of sodium thiosulfate provided definite pain relief for a short time after each injection and the gradual increase of the individual dose to 11 cc. over a

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

488

/

RESEARCH

IN

PHYSIOPATHOLOGY

twelve week period gave complete pain relief. During this time, the pa¬ tient’s general condition improved rapidly. Motion and sensation returned to the toes, feet and finally to the whole leg. By April, the patient was able to sit out of bed. By the end of May, she was ambulatory without requiring a brace or cane. Her only complaint was a mild facial acne that developed during the course of treatment.

Fig. 162. Anieroposicrior view of left shoulder region in Case E.H. four months after stopping testosterone and X-ray therapy at time of admission, showing involve¬ ment of entire left clavicle and continued spread in left seventh and eighth ribs pos teriorly.

Radiographic examinations were made at the beginning of treatment and each month thereafter. At the beginning, four months after the last X-ray treatment and doses of testosterone, osteolytic metastases were ob¬ served in all the vertebrae of the cervical spine and the bodies of the lower thoracic and lumbar vertebrae, with compression fractures of the third, fifth and ninth thoracic vertebrae. The entire pelvis was involved (Fig. 163) and there was destruction throughout the entire length of the left clavicle, in the left acromial process, both humeri and several ribs on the left side. (Fig. 162) Vascular markings were moderately increased in both lung fields.

Original from Digitized by

UNIVERSITY OF MICHIGAN

THERAPEUTIC

Fig.

APPROACH

163. Anteroposterior view of pelvis and upper

TO CANCER

489

Vi of both femurs in Case E.H.

at time of admission, showing widespread osteolytic process.

Fig.

164. Lateral view of thoracic spine in Case E.H. four mcn'.hs after beginning of

treatment, showing considerable bone regeneration in all vertebrae.

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

490

/

RESEARCH

IN

PHYSIOPATHOLOGY

Comparison with previous films showed definite evidence of continued spread of the metastatic process. Films in February showed no change, but in March, slight regressive changes were observed, especially in the left clavicle, left humerus and pelvis. During this time the urine became acid and remained so almost continuously. In April regressive changes were observed in the ribs, pelvis.

Fig.

165. Anteroposterior view of left shoulder region in Case E.H. four months

after beginning of therapy, showing considerable repair of left clavicular and rib lesions.

femurs and left shoulder girdle. Elsewhere no further involvement was noted. In July 1949, regressive changes were found to be continuing in all the involved bones. (Figs. 164, 165, 166) At this time, all medication was discontinued and the patient returned home. In August, the patient again complained of pain in the back, right thigh and left shoulder, and had increasing trouble walking because of difficulty in moving the right leg. The urinary pH again was alkaline. So¬ dium thiosulfate and sulfur in oil again were administered with relief of

Original from Digitized by

UNIVERSITY OF MICHIGAN

THERAPEUTIC

APPROACH

TO

CANCER

/

491

pain and considerable improvement in the ability to walk. A few months later the patient had a stroke from which she died in a few days.

Fig.

166. Anteroposterior view of pelvis and upper Vs of both femurs in Case E.H.

four months after beginning of treatment, showing considerable bone repair.

Hydronaphthalene Persulfides The exceptionally good results obtained with mercaptans in treating cancer in humans could only partially be reproduced by the different agents with bivalent sulfur in the polar group we tested. In addition to the hydroper¬ sulfides of the fatty acids, we tried to prepare and study other groups of persulfides. The great ability of the products of hydrogenization of naphthalene, such as tetrahydronaphthalene (tetralin)

and decahydro-

naphthalene (decalin) to fix oxygen as peroxides, led us to try to fix sulfur as persulfides on their molecules. These substances were treated with sulfur in conditions similar to those which led to fixation of sulfur to fatty acids. The agents obtained through this fixation on tetralin were particularly studied. We have mentioned the pharmacological study of these products. Based on their biological action, they appeared to be intermediary between mer¬ captans and fatty acids persulfides, with the big advantage of having a bearable odor. In humans, we utilized this produce in cases of which, most are still under observation. In general, the results obtained were good.

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

492

/

RESEARCH

IN

PHYSIOPATHOLOGY

Subjective changes and objective ones upon the tumors were obtained. We found that only minimal doses are to be used, corresponding to micrograms of sulfur and milligrams of tetralin. With these doses, no side effects were observed. When given slightly higher doses, some patients felt a sensation of weakness and also, in a few cases, of dizziness. This agent has shown a marked influence upon the existing patterns with a special facility to induce, in most cases, an offbalance of type D at the cellular level. With higher doses, the systemic offbalance which is also in¬ fluenced, can be changed back to offbalance type A only with difficulty. This fact indicates the need for reduced doses, acting almost exclusively at the cellular level. The dosage must be guided by a continuous control of the analyses, and especially by those of serum potassium for the cellular level and of urinary surface tension for the systemic. With values above 5 mEq potassium in serum (and low in blood red cells) and urinary surface tension of less than 68 dynes/cm., corresponding to a systemic offbalance of the type D, the decrease or even suppression of the medication is indicated. We utilized the agent in cancer cases where the rapid disappearance of the tumor appeared as the capital aim. More time is needed to judge the value of those results already obtained. Among the cases treated, the fol¬ lowing observation represents an interesting example. B. P., 32 year old male, was operated for a wart at the right ear 2Vi years before coming under our care. Pathological examination had revealed malignant melanoma. A month later, a dissection of cervical glands was made. The analyses of the obtained glands showed no cancerous cells. Two months before coming under our care, a checkup revealed a new tumor in the right side of the larynx. With the growth of the tumor, edema of the right face was also increasing. Examination showed a tumor 4 cm. in di¬ ameter on the right side of the larynx. The tumor was adherent to the skin. Laryngological examination showed the tumor protruding in the pyriform sinus. Because extensive surgery would have been necessary for the tumor removal, the patient refused such surgery. He was admitted and first treated with only limited change in the tumor. Treatment was changed to tetralin persulfides in a dose of 10 drops of a 10% solution in oil, administered 3 times a day. Under this treatment, the tumor involuted very rapidly, and practically disappeared in 3 weeks. Subjective feeling, such as dizziness, made us discontinue the administration of the preparation. The treatment was changed to epichlorohydrin and sulfur in the form of fatty acid hydropersulfides, administered in small doses. The patient has continued this treatment at home for the past 2Vi years with no apparent recurrences.

Digitized by

Google

UNIVERSITY OF MICHIGAN

THERAPEUTIC

APPROACH

TO

CANCER

/

493

Butanol, Glycerol During the period when mercaptans and other sulfur-containing agents were being studied, attention also was centered on butanol in the group of anti-fatty acid agents. While butanol’s effect upon pain and other subjec¬ tive manifestations appeared evident from the beginning of its use, the influence upon tumors seemed small. Together with glycerol, however, it produced several long-lasting objective changes. Characteristically, in most of these cases recurrences appeared only after many years of normal active life during which there was no clinical manifestation of cancer. In some cases, however, there were no recurrences.

Fig. 167. Myelogram of patient M.H. showing the flow of lipoidol arrested at the level of 4-T.

Mrs. M. H.—This 45-year-old patient experienced, in June 1943, sensory and motor disturbances which progressed so rapidly that in Sep¬ tember 1943 she presented a complete paraplegia below 4-T. She came under our care in February 1944, a paraplegic for 5lA months. The myelo¬ gram taken at that time showed complete obstruction, with the flow of lipoidol arrested within the spinal canal at the level of the 4-T. (Fig. 167)

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

494

RESEARCH

IN

PHYSIOPATHOLOGY

The urine analyses showed an offbalance of the type A, and she was treated with the acid lipid fraction of human placenta, and with hydropersulfides. The symptoms continued to progress and the pain was more severe. Following a change in the urine analyses toward the offbalance D, the treatment was changed to butanol and glycerol. The pain was controlled in a few days, and a slow regression of the paraplegia occurred. After four months of this treatment, there was complete remission and the patient was again ambulatory. The myelogram repeated at the end of November 1944, showed complete disappearance of the obstruction. (Fig. I6ti) The

Fic. 168. Myelogram of the patient M.H., showing the complete disappearance of the obstruction.

patient remained entirely well, without treatment and free of symptoms for eleven years. We were informed that, subsequently, a recurrence appeared, followed again by paraplegia and multiple lung metastases. The patient died after four months of paraplegia. Mr. I. H.—In 1938, at the age of 30, the patient underwent surgery for a tumor of the right parotid diagnosed as chondromyxosarcoma; in 1940, a recurrent tumor was removed and was followed this time by facial

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

THERAPEUTIC

APPROACH

TO

CANCER

405

paralysis. In 1943, another recurrence was treated surgically. In June 1945, the same procedure was repeated. Immediately after the last operation, there was still another recurrence and the tumor this time started to grow rapidly. Severe pain was only slightly relieved by narcotics. Radiotherapy was refused, in spite of the massive tumor and pain. The patient came under our care in December 1945, with several tu¬ mors occupying the right parotid region and extending below the mandibula. He was using various narcotics with little effect. With the urinary chloride retention index, pH and specific gravity as criteria, treatment with

Fig.

169. Patient I.H. with a recurrent chondromyxosarcoma of the right parotid

gland before and after treatment. The scar is from repeated previous surgical inter¬ ventions.

sodium thiosulfate and hydropersulfides was started. Under this treatment, which lasted a week, the lesion appeared to be unfavorably influenced and pain increased. With the urine chloride index used as a criterion, the treat¬ ment was changed. 1 cc. of butanol 6.5% was administered orally three times a day along with 0.3 cc. of glycerol. After 4 days, the dose of butanol was increased to 2 cc. three times a day. Pain was relieved in a few days. Rapid disappearance of the tumor masses followed. The same treatment was continued for one year. Since then, the patient has been well and is enjoying good health without any recurrence as of this date. (Fig. 169) E. M.—In 1935, at the age of 42, this patient had a right radical mas¬ tectomy for adenocarcinoma of the breast. In 1940, recurrent nodules ap¬ peared in the line of the scar. One of these was biopsied and showed a recurrent

adenocarcinoma. Grade

III.

The patient

was then

treated

with deep X-ray therapy, 3800 r. being delivered through five fields to the

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

496

/

RESEARCH

IN

PHYSIOPATHOLOGY

right chest and axillary regions. A daily dose of 200 r. was given for nine¬ teen days between December 1940 and January 1941, using the following factors: 200 kv., 25 ma., 50 cm., Vi mm. Cu and 1 mm. A1 filter. In May 1941, the wound area and recurrent nodules (Fig. 170) were excised and a skin graft was used to repair the defect. In July 1943, skeletal metastases, predominantly osteolytic in nature, were reported in the fourth, fifth and twelfth thoracic vertabrae and first, second, fourth and fifth lumbar vertebrae, the first sacral segment and the left ala of the sacrum. There was also involvement of the outer portion of the left ilium and the inner portion of the right ilium near the sacroiliac joint. The patient received a second course of deep X-ray therapy over the spine and posterior pelvis, the total dose being 3800 r. with the same fac¬ tors. Following this, her menses ceased. The pain in her back, which had confined her to bed, was considerably relieved and she became ambulatory. By January 1944, however, pain had recurred and the patient was again confined to bed most of the time. X-ray studies showed metastatic involvement in practically every thoracic vertebrae, especially marked in the fourth, fifth, eighth and twelfth. All the lumbar vertebrae were involved.

Fig. 170. Photomicrograph of recurrent skin nodule in Case E.M., showing adeno¬ carcinoma. Gr

111

(400 x).

«zed by GOV. tgle

UNIVERSITY OF MICHIGAN

THERAPEUTIC

APPROACH

TO

CANCER

/

497

especially the first, fourth and fifth bodies and transverse processes. De¬ posits were present throughout the sacrum, in both iliae, the right ischium, left acetabulum and upper femurs. Another series of deep X-ray treat¬ ments was used on the same areas of the spine and posterior pelvis as before, the total dose this time being 2000 r., using the same factors. There

was again relief of pain, although the patient was kept in bed and a body brace was applied to reduce pain associated with motion and to avoid fracture. We first saw the patient on March 9, 1944. She had moderately severe back pain, was confined to bed with a back brace, and complained of weakness. Blood pressure was 90 systolic, 60 diastolic. Operative scars of

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

498

/

RESEARCH

IN

PHYSIOPATHOLOGY

the right chest region were well healed and there was no evidence of local recurrence of the tumor. There was no superficial lymphadenopathy. The liver area was tender to pressure on deep inspiration but the liver was not palpable. There was tenderness over most of the vertebrae with pressure. Patellar reflexes were hyperactive bilaterally. X-rays showed widespread skeletal metastases involving the dorsal and lumbar vertebrae, the sacrum and the pelvis. The lesions were predominantly osteoplastic. (Figs. 171, 172,173)

Fig. 173. Anteroposterior view of pelvis in Case E.M. showing widespread metastatic involvement in fifth lumbar vertebrae, sacrum, both iliac and femurs, two months after onset of treatment.

The patient was hospitalized and treated experimentally from March 8 to December 5, 1944, a total of nine months. The substances employed were n-butyl alcohol, cholesterol and glycerin, administered singly and con¬ currently at different periods. n-Butyl alcohol was administered as satu¬ rated water or saline solution (7.9% ) in doses of from 3 drops every two hours to 20 cc. three times a day by mouth, or from 1 to 5 cc. three times a day. 2.5% cholesterol in neutral oil solution was administered intra¬ muscularly in doses of 1 to 8 cc. three times a day. Glycerin was employed orally in 0.5 to 1 cc. doses three times a day. Dosages of all medication were increased progressively, the aim being to bring about and maintain alkalization of the urine. At the time of admission, the daily urine pH was almost constantly

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

THERAPEUTIC

APPROACH

TO

CANCER

499

acid. After five months of treatment, the urine became alkaline and re¬ mained so until the patient was discharged from the hospital. (Fig. 174) Clinically, pain was completely relieved after about one month. The patient’s appetite improved and she began to gain weight and to feel stronger. After five months, she was mobilized with a brace and showed good progress in the ability to walk. No changes were observed in monthly X-ray studies during the first four months of treatment. In the X-rays taken in July, the fifth month, at the time of urinary pH change, a few lesions began to show areas of de¬ creased density. These changes progressed fairly rapidly thereafter.

Fic. 2 Fig. 174. pH of daily morning urine specimens in Case E.M. determined colonmetrically, showing changes from acid lo alkaline 5 months after the beginning of the treatment.

Following her discharge from the hospital, the patient continued to take 0.25 cc. of glycerol three times a day for another six months. All medication was discontinued after that and the patient has received no further treatment since. She returned to her old clerical position and after several years, when the X-ray changes appeared to warrant it, the brace was removed. X-ray pictures taken fifty-seven months after beginning of the experi¬ mental treatment, (Figs. 175, 176, 177) no longer showed osseous pathology and indicated virtually complete restitution of normal appearing bone. The clinical condition was excellent and remained so in 1956, when we saw her. We were indirectly informed that later, in Texas, she suffered a right pleural effusion and died shortly thereafter. M. H.—In February 1948, at the age of 18 months, this patient was admitted to the Good Samaritan Hospital in Dayton, Ohio, because of

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

500

/

RESEARCH

IN

PHYSIOPATHOLOGY

abdominal pain. An exploratory operation revealed an obstruction caused by a tumor of the bowel that had spread to the lymph nodes throughout the abdomen. A by-passing operation was performed to relieve the obstruction. A piece of the mass and some of the involved lymph nodes were removed. The pathological diagnosis was fibro-sarcoma.

Fio. 175. Anteroposterior views of thoracic spine in Case E.M. fifty-seven months after onset of therapy, showing almost com¬ plete restitution of normal bone structure.

Fig. 176. Lateral view of tho¬ racic spine in Case E.M., fiftyseven months after onset of therapy, showing almost com¬ plete restitution of normal bone structure.

On March 3, 1948, the patient came under our care. At that time, al¬ most a month after surgical intervention, a mass the size of a tangerine was found in the right side of the abdomen. Based upon her analyses, the pa¬ tient was treated with Vi cc. glycerol and 2 cc. of butanol solution three times a day. She continued the same treatment without interruption for

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

THERAPEUTIC

APPROACH

TO

CANCER

/

501

two years, gained weight and grew, and no recurrences were noted. It is now 12 years since this little girl started treatment. She is well, attending school, and carrying on all the usual activities of a child of her age. Paralleling these clinical investigations, a study was made of the elimi¬ nation of surface-active substances. This led to the use of surface tension as a criterion for the recognition of ofTbalance patterns. A series of cases was treated according to this criterion. With the progress of research, new agents also were utilized.

Fio. 177. Anteroposterior view of pelvis in Case E.M. fifty-seven months after on¬ set of treatment, showing almost complete restitution of bone structure.

Conjugated Fatty Acids In 1947, we started therapeutic trials of conjugated fatty acids, first using eleostearic acid, the conjugated tricne obtained from tung oil, ad¬ ministered orally or parcnterally. The effects upon pain, systemic changes and particularly tumor evolution, were not up to expectation although sub¬ jective changes were immediately more manifest than for unconjugatcd fatty acids. In a short time, however, it was found necessary to continuously increase the dosage in order to maintain the effects. The intervention of a defense mechanism against these preparations often was evident. Cancer patients who had responded to administration of eleostearic acid with relief of pain and even with an arrest of tumor growth were found to require increasing amounts of this substance. After a while, they no longer

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

502

/

RESEARCH

IN

PHYSIOPATHOLOGY

responded. Even very large amounts of this conjugated fatty acid, well tolerated in these cases, no longer had an effect upon the tumor and its manifestations. This fading effect limited the clinical usefulness of eleostearic acid. In this respect, it appeared to resemble many other constitu¬ ents or even heterogeneous agents which have therapeutic effects that fade rapidly. We have noted previously that intervention of the adrenals is directed especially against the conjugated trienes, substances related to traumatic noxious influences. Therefore, we tried to utilize other conjugated members, some with a higher number of double bonds, in the hope that the body would not be able to efficiently fight their intervention. We obtained con¬ jugated fatty acids with four double bonds by treating mixtures of fatty acids rich in arachidonic acid, such as salmon oil, then fractionating the mixtures through their solubility in solvents, especially acetone, at low temperatures. We also obtained the same type of compound directly from parinarum laurinum nuces as parinaric acid, a tetraconjugated acid. Con¬ jugated pentaenic and hexaenic acids were isolated from the mixture of conjugated fatty acids obtained from salmon, sardine and cod liver oils. When these preparations were tried in patients with cancer, no apparent improvement over the results obtained with mixtures of non-conjugated fatty acid was seen. Having in mind the plurality of levels at which they would act, and especially considering the influence exerted by methylcholanthrene upon carcinogenic activity, mixtures of fatty acids from cod liver oil, sardine oils and from normal organs and tissues were conjugated and used. While the effects on pain and systemic changes were more intense and longer lasting, the effects upon tumors were not strikingly different from those obtained with the non-conjugated isomers. Of approximately 140 cases in which these conjugated fatty acid preparations were used, 45% showed subjective changes. In 25%, objective changes occurred, including clinical disappear¬ ance of malignant tumors in a few cases. Most of these results, however, were temporary. The tumors later grew again and no longer could be controlled by administration of these lipids. In some cases, the good results persisted and the following illustrates three of these cases. B. T., 46 years old, had a left mastectomy in 1948, for an adenocar¬ cinoma. 1 Vi years after the operation, progressively increasing generalized pain appeared, with the general condition going rapidly downhill. Pain, more than the general condition, obliged her to become totally bedridden. Successive X-ray examinations

Digitized b

Google

showed

rapidly

progressing

osteolytic

original rrom UNIVERSITY OF MICHIGAN

THERAPEUTIC

APPROACH

TO

CANCER

503

lesions. X-ray treatment for three regions was started with the intention to control the pain which was most severe in skull, ribs, spine, pelvis and femurs. Because of the general condition, this was discontinued after a few treatments. When the patient came under our care, she was entirely immo¬ bilized and in severe pain. X-rays revealed (Figs. 178, 179) multiple osteo¬ lytic metastases in skull, femur, pelvic bones, spine. In view of the analysis

'tv 12-26 50 Fig. 178. Lateral view of the skull of patient (B.T.) at the time of admission, show¬ ing multiple osteolytic metastases.

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

504

/

RESEARCH

IN

PHYSIOPATHOLOGY

as a typical A offbalance, treatment with hydropersulfide and conjugated fatty acids was instituted. In her case we saw a peculiar form of response encountered also in several other subjects, and which we considered in general as corresponding to as a favorable response. During the treatment, while pain in general was relieved, one lesion was seen to become progressively more painful. It re¬ mained severely painful for 2-3 days after which the pain disappeared. The same change was seen to occur successively in one lesion after another with the same temporary increase of pain until it became very severe, followed by disappearance after 2-3 days. Not only did the pain fail to return in the same lesion, but usually the lesion was seen to involute after such a change. With this kind of treatment the patient made a very rapid recovery and was out of bed in less than two months. The radiological changes, although showing progressive repair of the osteolytic lesions, took more time to be completed Fig. 181 shows the healing of the bone metastases in prog¬ ress, while Figs. 180 and 182 the results after almost 2 years. The patient

Fig. 179. Anteroposterior view of the pelvis and upper parts of the femurs of the patient (B.T.) showing multiple osteolytic metastases.

Digitized

b)

Google

Original from

UNIVERSITY OF MICHIGAN

THERAPEUTIC

APPROACH

TO

CANCER

/

505

resumed normal life for 3 years after which recurrences appeared on skin, lung and liver. These responded less favorably to the same treatment. The patient left our care and died a few months later. Mrs. S. T., 47 years old, came under our care in a subcomatous state, 2x/i years after a left breast mastectomy for an adenocarcinoma. For three months before, the patient complained of generalized pains and especially of severe headaches, and for a month had symptoms of diabetes insipidus.

Fig. 180. Lateral view of the skull of patient (B.T.) after 22 months of treatment. Most of the lesions have disappeared.

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

506

/

RESEARCH

IN

PHYSIOPATHOLOGY

An X-ray examination of the skull, made prior to her admission (Fig. 183) showed extensive skull metastases with an advanced destruction of the clinoid bones. Because of the diabetes insipidus, the urine analyses could not furnish the needed indication for the treatment and we recurred, therefore, to the number of blood leucocytes and to the body temperature, as tests able to

Fig.

181. Anteroposterior view of the pelvis and femurs of patient (B.T.) after four

months of treatment, showing the lesions decreasing.

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

THERAPEUTIC

APPROACH

TO

CANCER

/

507

indicate the existing offbalance. With 14,500 leucocytes and a constant temperature of above 98.6 F, we considered the offbalance to be of the type A and administered conjugated fatty acids obtained from cod liver oil, and sodium thiosulfate together with posterior pituitary hormone for her diabetes insipidus. Probably due largely also to her electrolytic balance the patient regained consciousness and made a rapid recovery. In less than

Fic.

182. Anteroposterior view of the pelvis and femurs of patient (B.T.) 2 years

later, showing most of the lesions disappeared.

two weeks she was out of bed and resumed a normal life. She continued with the same treatment on an ambulatory basis. An X-ray examination four months later showed a manifest healing of the previous lesions. (Fig.

184) After another four months however, without any recurrence of her malignancy the diabetes insipidus could not be adequately controlled. She refused hospitalization and left our care. She died a short time later with symptoms of electrolytic offbalance. Mr. L. N., 64 years old. had a long history of vesical troubles, with

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

508

/

RESEARCH

IN

PHYSIOPATHOLOGY

biopsies showing cancerous lesions. In spite of repeated figurations, the vesical tumors grew rapidly with constant hematuria and tenesmus. Three months before coming under our care, the patient suffered severe pains in the left groin which X-ray examination showed to be due to a bone metastatic lesion. Fig. 185 depicts the lesions upon admission. The anal¬ yses showed an offbalance type A, and a treatment with conjugated fatty acid obtained from cod liver oil and sodium thiosulfate was instituted. The pain disappeared in a few days, as did the hematuria and dysuria. The pa¬ tient continued to improve. An X-ray examination, four months after treatment was started, showed the appearance of a callus at the place of the bone metastases. (Fig. 168) The patient continued the treatment for a few more months after which time we lost track of him. Heterogeneous Agents

Because of the organism's defense against the fatty acids with which it comes in contact under normal and abnormal conditions, more hctero-

Fig. 183. Lateral view of the skull of patient (S.T.) processes.

showing multiple osteolytic

Original from Digitized by

UNIVERSITY OF MICHIGAN

THERAPEUTIC

APPROACH

TO

CANCER

/

509

geneous agents were sought. We first resorted to the alpha hydroxy fatty acids. Isolated members and mixtures of the acids, after being prepared and tested for toxicity in animals, were used in patients. We have discussed previously the striking and specific effect obtained upon lymphosarcoma in C3H mice with alpha hydroxy caprylic acid. Although we were not able to account for this effect, we did attempt to determine whether the acid would have a similar favorable influence upon human lymphomas, especially

Fig.

184. Lateral view of the skull of patient (S.T.) showing most of the lesions dis¬

appeared.

Original from Digitized by

UNIVERSITY OF MICHIGAN

510

/

RESEARCH

IN

PHYSIOPATHOLOGY

Hodgkins’ disease. Several patients with Hodgkins’ disease were treated by oral administration of preparations of alpha hydroxy fatty acids from caproic to stearic acids, or with mixtures of them. Only in a few subjects were very limited effects, such as a small decrease in the lesions, observed. Changes were not considered to exceed those known to occur spontane¬ ously in such cases. These effects were inferior to those obtained with the

Fig.

185. Anteroposterior view of the pelvis of a patient with an adenocarcinoma of

the bladder, showing the destruction of the left ischion hone.

fatty acid preparations previously tested. There were no effects upon evo¬ lution of other lymphomas or in other types of cancer. Alpha hydroxy preparations produced limited subjective changes in less than 10% of cancer patients, and no marked objective changes at all. Other heterogeneous fatty acid preparations were obtained and, after study of their pharmacological activities, were applied in humans. Polyhydroxy fatty acids, peroxides of fatty acids, and fatty acids in which chlorine was fixed at the double bonds, were tested in only a limited num¬ ber of patients, but enough cases to show that effects were no different from those obtained with conjugated fatty acids, for instance.

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

THERAPEUTIC

APPROACH

TO

CANCER

/

511

Parallel to these efforts to find new agents for patients with the one type of offbalance, other agents for use against the opposite type of offbalance were investigated. Sterols and nonsaponifiable fractions were treated in various ways to obtain heterogeneous substances not found in living organisms. We used heat at 300°C or ultraviolet light, according to the procedures employed by Roffo, in order to induce changes in sterols which would tend, accord-

Fig. 186. Anteroposterior view of the pelvis of patient of Fig. 185, 4 months later, showing the healing of the lesion.

ing to him (198) to make them carcinogenic. We considered these heat or ultraviolet treated sterols and nonsaponifiable fractions to represent ab¬ normal lipoids. They were administered in oily solutions to animals and to a few patients with advanced malignancies. Injected intramuscularly daily for a few weeks, they induced no undesirable results. Their effects upon pain and systemic changes were not significantly different from those of corre¬ sponding untreated preparations. The studies of other changes in cancer patients treated with these preparations do not allow any conclusions to be drawn at this time.

ized by

Google

UNIVERSITY OF MICHIGAN

512

/

RESEARCH

IN

P H Y S I O P A TH OL OG Y

We prepared and studied various sulfurized fatty acids, of which the conjugated were used on a broad scale in therapeutic trials. Clinically, these sulfurized fatty acids produced marked results in several cases, but did not constitute a significant advance over sulfurized oil in which sulfur was bound to triglycerides rather than to free fatty acids. In the search for more active thiolipoids, we prepared several products, one of which, methylthioglycolate, was given a broad clinical trial. Although it produced some interesting objective results, they were neither sufficiently intense nor consistently reproducible nor persistent enough to make methyl¬ thioglycolate a distinct advance over the other sulfur preparations used. The compound also had the disadvantage of disagreeable odor although it is not as obnoxious as the mercaptans. As a result, we abandoned the use of this substance after a year of clinical experiments. Of 131 patients treated with methylthioglycolate, 39—or 30% showed subjective changes and 19—or 15%, also showed objective positive changes. Another synthetic thiolipoid, hexylthionic acid, was utilized in a few clinical cases. Only a small number of patients showed objective clinical results and these were neither consistent nor persistent enough to warrant using this substance for further research. While the results obtained with agents other than mercaptans having a thiol polar group were interesting, these compounds had too little influence upon tumors, especially in cases where the pattern indicated persistent predominance of sterols. Selenium Preparations

We have previously noted the considerations which led us to study lipoidic compounds containing bivalent selenium. The compound used in clinical research was hexyldiselenide, a lipoid with an -Se-Se- as a polar group. Oily solutions in various concentrations were given by subcutaneous or intramuscular injection. Doses as low as 4 micrograms or as high as 400 milligrams were employed several times a day. For oral administration, capsules containing the product in solution in hydrogenated oil in amounts from 4 micrograms to 100 milligrams were employed. A short time before the experimental therapeutic use of selenium compounds, the means of recognizing the existing offbalance were implemented with the sulfhydryl index, a measure of urinary elimination of the sulfhydryl group. Despite negative results in animal tumors, hexyldiselenide was used clinically in the hope that, with treatment guided by the data furnished by urinalyses, satisfactory results could be obtained. The sulfhydryl index served, at the beginning of this study as the principal indication for the administration of the selenium compound. Later we used urinary surface

Google

UNIVERSITY OF MICHIGAN

THERAPEUTIC

APPROACH

TO

CANCER

/

513

tension as the criterion, and lately we have used the changes in serum and total blood potassium. In general, we administered the medication only if the sulfhydryl index was below 1.5, the surface tension above 68. A marked influence upon the tumor itself was seen in a relatively high pro¬ portion of cases. The results also are of theoretical interest since the com¬ pound had less influence upon symptoms at the tissue level, such as pain, or at the systemic level, and more on those at the cellular level. The effect on pain was slow to appear, often requiring days. But once relief of pain was achieved, it persisted for a long time, in contrast to the brief effect produced by other agents such as thiosulfate or hydropersulfides acting directly at the tissue level. Primarily because hexyldiselenide alters the pattern present at the cellular level, it must be emphasized that determining proper dosage at least in the beginning, appeared more difficult than foi any other substance with which we have had experience. At the beginning, we used doses in the range of 10-80 mg. but in a number of cases a persistent change to the opposite pattern occurred after one or two doses. This led to the utilization of smaller and smaller doses in order to avoid too rapid change to the opposite pattern. Also with small doses, we hoped to limit the therapeutic response to the cellular level only. We decreased the daily dose to 5 mg., then to 1 mg. and eventually even to micrograms. With these small amounts, the immediate clinical effects seemed to be almost entirely limited to the cellular level. The changes in pain and the systemic pattern were minimal. The choice of dose to be given was determined in the second part of this research primarily by urinary sur¬ face tension. It was observed that microgram doses may influence lesions without changing the values of the other analyses corresponding to the systemic level. The clinical results obtained with the use of hexyldiselenide in humans warrants detailed consideration. Good results were obtained with greater consistency after the problem of dosage was resolved and the relationship to urinary analyses was established. Important objective changes could be achieved by using urinary analyses as a guide for dosage, as illustrated by the following cases. A. B., 68 years old, male. In October 1949, the patient had an ampu¬ tation of the left leg at the hip-joint performed at the Memorial Hospital because of a tumor of the femur. The pathological diagnosis was sarcoma. He was well until July 1955 when he began to cough and have recurrent episodes of hemoptysis. X-ray examination revealed right pleural effusion and infiltration of the right lower lobe. He was readmitted to Memorial Hospital in October 1955 and thoracentesis revealed bloody fluid. Bron-

Google

UNIVERSITY OF MICHIGAN

514

/

RESEARCH

IN

P H Y S I O P A T H O LO G Y

choscopy showed partial narrowing of the right lower lobe bronchus. Ex¬ amination of pleural fluid and bronchial washing by the Papanicolau method showed cells that were suspicious for malignant disease, but not conclusive. It could not be determined whether a primary lung cancer or metastatic sarcoma was present. An exploratory thoracotomy was advised but refused by the patient, who signed himself out.

Fig. 187. Anteroposterior view of chest in Case (A.B.) at time of admission showing the presence of a mass in the lower part of the right hemithorax.

Two weeks later, he came under our care and has been an ambulatory patient since then. His chest pain had been considerably relieved with the thoracentesis and there was no bleeding. He complained of distress and tightness in the chest as well as perspiration at night. A physical examina¬ tion revealed dullness in the lower right hemithorax below the seventh rib. Blood pressure was 208/165. X-ray examination revealed a large round mass occupying the right lower lobe. (Fig. 187) Urinalyses showed a low surface tension, low specific gravity, high pH and low sulfhydryl excretion. Hexyldiselcnide was chosen as the only chemotherapeutic agent. Treatment was started with a tenth of a milligram

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

THERAPEUTIC

APPROACH

TO

CANCER

515

twice a day, and was increased gradually to half a milligram twice a day. Chest pain and hemoptysis decreased in the following weeks. The general condition improved. He felt better and had no cough. X-rays a month and a half later showed that the right lower lobe mass was slightly smaller in size. In January 1956, a striking reduction in size and density of the lower right lobe mass was seen. It was now about 60% as big as a month before.

Fio. 188. Anteroposterior view of the chest of the patient A B. after ten months of treatment with hexyldiselenide.

At the beginning of February, the mass in the right lower lobe was almost entirely gone. The interlobular thickening of the left lower lung still per¬ sisted. In April, further clearing of the right lower lobe was seen. (Fig. 188) The patient received treatment with hexyldiselenide for a few more months. He continued in excellent condition without further treatment for the next three years. At the end of that time, there was a recurrence of pain and the mass in the right lower lobe reappeared and grew rapidly. Treatment with hexyldiselenide was resumed. The pain disappeared again within a short time, and the tumor again regressed.

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

516

/

RESEARCH

IN

P H Y S I O P AT H O L O G Y

I. A.—This 58-year-old patient had diabetes beginning at the age of 30. It was controlled by insulin. At 35, he had rheumatic fever and re¬ mained in bed for 6 months. Angina developed at 53. In January 1956, he was awakened by a pain in the right side of the abdomen. The pain con¬ tinued to be severe for months and the patient lost weight. Barium enema revealed nothing. He entered Jewish Hospital in Brooklyn with jaundice in April 1956. Upon operation, the gall bladder was found enlarged to twice its normal size and the common duct was dilated. With a finger in¬ serted through the foramen of Winslow, a hard, stony mass involving the head, body and most of the tail of the pancreas, was felt. The tumor in¬ volved almost the entire pancreas. The lymph node of the common duct was enlarged. The liver showed no evidence of metastases. The general con¬ dition of the patient, in spite of the extensive involvement of almost the entire pancreas, did not justify a total pancreatectomy. Therefore, a pallia¬ tive surgical procedure was done. The gall bladder was anastamosed to the jejunum. The post-operative course was good. No other treatment was pre¬ scribed. When the patient came under our care at the end of May 1956. the jaundice had disappeared but the pain was the same as it had been before operation. A mass occupying the upper abdomen was felt. Treat¬ ment was started with a dose of 30 micrograms of hexyldiselenide a day. This dose was increased later to 300 micrograms a day. The abdominal discomfort lessened; pain in the upper abdomen disappeared. The patient remained on this treatment until 1957 when epichlorohydrin was added to the hexyldiselenide. With the mixed treatment, the patient continued to improve and the tumor, which had been palpable in the upper abdomen, disappeared after a few months. Except for diarrhea, which occurs from time to time, the patient has made a very good recovery. He has continued on hexyldiselenide and epichlorohydrin and, at present, four years later, is in good general condition. No tumor can be felt and he is at his regular job. C. M., 52 years old, male. In 1946, the left breast of this patient was removed because of a malignant tumor. In 1947, the right breast was re¬ moved but the tumor proved to be benign. In 1954, the patient, showing blood in the urine, was admitted to the Presbyterian Medical Center where a right kidney tumor was diagnosed. In February 1955, the patient under¬ went surgery. A tumor of the right kidney with extensive lymph node involvement above and below the renal vessels was found. A simple neph¬ rectomy was performed, the lymph nodes being considered inoperable. The pathological report revealed “clear cell carcinoma of the kidney with ex-

Digitized by GoOglC

UNIVERSITY OF MICHIGAN

THERAPEUTIC

APPROACH

TO

CANCER

/

517

tension into the renal vessels and surrounding tissue.” There was no evi¬ dence of pulmonary or other metastases. The patient did not undergo any treatment at this time and felt well until September 1955, when he experienced increased fatigue, flatulence, slight pain in the right kidney region, and some abdominal pressure. No abdominal mass or lymph node involvement was found. He was treated with hexyldiselenide, starting with 200 micrograms a day. This dose was increased progressively until it reached 2 Vi milligrams a day. Under this treatment, most of the patient’s pain disappeared and no palpable mass could be found. The patient continued treatment, with the same dose, until October 1957, when epichlorohydrin was added. At first, with the new medication, the patient was more tired and there was a no¬ ticeable increase in perspiration. However, after a short time, he continued to improve. At present, he is still taking 15 milligrams of epichlorohydrin, and 100 micrograms of hexyldiselenide daily. He feels well, continues nor¬ mal work, and no tumor is palpable now four and a half years since the beginning of the treatment. W. H.—In March 1954, at the age of 11, this boy had the first of three brain operations at the Jersey City Medical Center. He had complained of persistent headaches for about a year. A brain tumor was removed and on pathological examination, was first thought to be benign, but later proved to be malignant (spongio-blastoma). By August of 1954, his symptoms recurred and a swelling appeared in the area of the scar. At the second operation, it was possible to remove only a part of the recurrent tumor. In November 1954, local swelling and headaches returned. X-ray treatments failed to give relief and a third operation was performed, but only a piece of tumor was removed. It showed the same pathology. He came under our care May 3, 1955, and was treated, because of low sulfhydryl urinary index, with hexyldiselenide, in dosages ranging from 300 micrograms to 1 milligram per day. This treatment was continued for one year. He has done remarkably well since. He has had no headaches, is more alert and less drowsy than at any time since he first became ill. There has been no evidence of recurrence. Since treatment, there has been a definite reduction in involuntary movements of his head, extremities and body, which appear to have been related to the tumor growth. There have been no abnormal manifestations to date, five years since the beginning of the treatment. The patient goes to school and engages in all the activities of a normal boy of his age. Mrs. A. L.—This patient first noted a lump in her neck in the summer of 1953 when she was 26 years old. In February 1954, a second lump

Google

UNIVERSITY OF MICHIGAN

518

/

RESEARCH

IN

P H Y S I OP A TH O LOO Y

appeared. Surgery was performed at the Ottawa Civic Hospital. The patho¬ logical examination showed a cancer of the thyroid (papillary adenocar¬ cinoma). It involved both sides of the gland and many of the lymph nodes. The entire thyroid gland was removed and bilateral lymph node dissection was done in two stages. Since the surgeon felt that he had not removed all the affected areas, the patient received deep neck X-ray therapy follow¬ ing the operation. However, by July 1954, a new mass developed on the right side of the neck and this was removed in November. The patho¬ logical examination proving it to be the same type of tumor. The patient was first seen by us on January 10, 1955. Although it was only two months since the last operation, there were several recurrent tumor masses in the lateral right side of the back of the neck, as well as infiltrations into the area of the last operative wound. The patient was treated with hexyldiselenide, in doses ranging from 300 micrograms to 1 milligram daily. Under this treatment, the masses progressively decreased and, after 3 months, disappeared. She continued the treatment for another six months. Now, after 5 Vi years, she is feeling well, has had no recur¬ rences, and is carrying on her usual activities as a housewife and mother. Hexyldiselenide, although it produces impressive results, very often is not of itself able to provide enduring benefit. Many other patients have had recurrences, some in spite of impressive first results and continuation of treatment as shown in the following observation. J. D., 10 years old, came under our care in a preterminal state, after an exploratory laparotomy revealing an extensive carcinoma of the liver. (Fig. 189) The response to hexyldeselenide treatment was impressive with the patient making a perfect recovery. His liver which had filled the abdomen, returned to normal di¬ mensions. The patient continued a normal life for 2 years when, in spite of the continuation of the treatment, generalized recurrences appeared. These could no longer be controlled. Tetralin Perselenide The good effects obtained with persulfides on one hand, and with selenium on the other, have led us to investigate the corresponding com¬ pound—tetraline perselenide. With its low toxicity, the compound was ad¬ ministered to humans in which the destruction of the tumor appeared the immediate aim. The effect upon pain was good although not immediate, the same as for the systemic level. It was at the cellular levels where these were the most manifest. Research with this agent is still in progress and for the moment the influence exerted upon the tumors seems to be very fa-

Digitized b

Google

UNIVERSITY OF MICHIGAN

THERAPEUTIC

APPROACH

TO

CANCER

/

519

vorable. Similar good results were obtained with naphthalene perselenide and other similar preparations of aromatic hydrocarbons. Parallel to studies with synthetic negative lipoids, synthetic positive lipoids were investigated. The problem was quite different because of the fundamental differences in biological roles of the two antagonistic groups. Among negative lipoids we singled out an effect against sterol predominance and a destructive activity through the induction of rapid cellular aging.

Fig. 189. Photomicrograph of a liver biopsy of patient J.D.

Among the positive lipoids, we sought agents able to correct the noxious effects induced by fatty acids. As noted previously, this led to a search in one group of experiments for substances with higher specificity for binding particular fatty acids and in other experiments for substances with broad spectrum acting against acid lipids in general. We have discussed previously the pharmacodynamic characteristics of many of these synthetic positive lip¬ oids. Clinical results have improved with the development not only of new substances but also of new means of recognizing the pattern present and of following the changes that take place. We have mentioned the results

Google

MUI

lu

Ivill

UNIVERSITY OF MICHIGAN

520

/

RESEARCH

IN

P HY S I O P A T H OL OG Y

obtained with butanol, the first of this group of synthetic lipids with positive character to be used in humans. Butanol was unable by itself to influence the growth of tumors, although it was effective in controlling pain of an alkaline pattern. This beneficial effect upon pain was still more manifest for other aliphatic alcohols, and especially for heptanol. In high doses, however, heptanol probably acts beyond the tissue level. Besides influencing pain, it induces severe edema and changes in the evolution of the tumor. It has little influence at the systemic level upon hemorrhage, even with high doses. For tumors with offbalance of type D, a mixed treatment appeared indicated. The use of heptanol-butanol, however, was not fully satisfactory although it has been employed in some cases with good clinical results. During the progress of this research, it became increasingly important to have an accurate knowledge of the existing ofFbalance, and of the ade¬ quate use of the available therapeutic agents. The following observations show how the results obtained by the treatment are a function of the correct application of this concept of guided chemotherapy. M. S.—This 52 year old woman started to lose weight in September 1953 and her abdomen became very distended several months later. An exploratory laparotomy was done in July 1954 at Brooklyn Hospital and revealed a large mass in the lower abdomen with metastases. A lymph node biopsy was performed and showed lymphosarcoma. (Fig. 190) Sub¬ sequently, she had 36 X-ray treatments, followed by another course of 12 X-rays, the last in December 1954. She felt relatively well until the first week in February when abdominal pains recurred. A mass in the middle abdomen, the size of a large grapefruit, could be felt. Under treatment with sterols, the tumor first increased slightly in size so that by the middle of April, it extended, filling up the entire left side of the abdomen. At the end of the month, the pain became stronger while the abdominal mass remained unchanged. The patient was treated, accord¬ ing to her analyses, with 1 mgm. of hexyldiselenide daily. The tumor be¬ came much reduced in size. Pain recurred at intervals and, although only a small mass was still palpable after 1

years of treatment, the patient’s

general condition started to deteriorate at that point. Analyses then revealed a change in the pattern present. The treatment was changed to a mixture of higher alcohols—octanol, heptanol and polyconjugated alcohols. The tumor rapidly regressed and, at the beginning of 1957, the mass had en¬ tirely disappeared. She continued in good general condition until August 1957 when she had a coronary occlusion. At present, two years later, the

Diqitized b

Google

UNIVERSITY OF MICHIGAN

THERAPEUTIC

APPROACH

TO

CANCER

/

521

patient is in good general condition and without any sign of recurrence of the tumor. In this case, the first treatment with sterols, using urinary pH as a criterion, brought some subjective improvement but this could also be con¬ sidered to be the result of the radiation. The improvement was transitory and the appearance of more symptoms, probably reflected the waning effect of radiation. The change to hexyldiselenide brought improvement but could

Fig. 190. Photomicrograph of a lymph node of patient

M.S. showing a lympho¬

sarcoma.

not entirely control the condition. It was with higher alcohols that im¬ portant objective as well as subjective changes were achieved. The tumor decreased rapidly. Interruption of treatment, due to the cardiac condition, did not seem to influence the favorable progress of the condition. M. B.—Toward the end of 1950, at the age of 45, the patient began to complain of right lower quadrant and intermittent left upper quadrant pain. She discovered an abdominal mass by herself. In February 1951, an exploratory laporatomy was performed at Lenox Hill Hospital with the following findings: “Situated in the left side of the pelvis, a huge cystic structure the size of a football was found. The superior wall of this mass was attached to the mesentery of the loop of the small bowel. The anterior

Google

UNIVERSITY OF MICHIGAN

522

/

RESEARCH

IN

P H Y S IO P A TH OLOO Y

cyst was attached to the posterior leaf of the broad ligament and contained the left ovary. On the ovary and within the wall of the cyst were several papillomatous structures. On the right side of the pelvis was another cystic mass containing a greenish turbid fluid. This cyst contained the right tube and ovary and on its walls were several papillomatous projections. The parietal peritoneum, the liver and omentum were studded with tumor im¬ plants and several sections of bowel were matted together by the same tumoral tissue. Biopsy specimens were obtained from several areas.” The gross pathological diagnosis was papillary carcinoma of the ovary with metastases to peritoneum, liver, intestines and duodenum. The report on the frozen section was malignant. Microscopic examination confirmed the diagnosis given at the time of the operation and revealed a fibroid fatty tissue extensively infiltrated by a malignant neoplasm of epithelial origin. The patient came under our care 11 days after her operation. The ab¬ dominal mass was palpable, rising from the pelvis to a level slightly above the umbilicus. Vaginal examination revealed large cystic masses filling both fomicis and cul-de-sac. The pelvic structures were partially fixed. The uri¬ nary specimen showed a pH between 7.4 and 7.8 and the surface tension was 68 to 71 dynes/centimeter. Treatment was instituted with a mixture of conjugated fatty acids, derived from cod liver oils, and a preparation of hydropersulfides as well as sodium thiosulfate. The first preparation was administered intramuscularly in a 5% oil solution in doses of from 2 to 4 cc. daily. The sulfur preparation (corresponding to 0.5% sulfur) and 10% solution of thiosulfate were administered in doses ranging up to 6 cc. daily. The treatment was continued without change for 1 year and 8 months. The abdominal mass was found somewhat smaller a month after starting treatment. A month later, a surgeon’s report showed that the tumor was about VS the size at the time of operation. After several months, no mass could be felt on abdominal and vaginal examination. After twenty months, the treatment was discontinued for one year. At the conclusion of this period, the patient began to relapse and a cystic mass in the cul-de-sac, palpable under finger examination, was found. Treatment with the same medications as before was instituted but did not change the dimension of the recurring tumor. Despite treatment, the tumor continued to grow and in April 1954, the abdomen was distended. X-ray also revealed a large liver and elevation of the right diaphragm. The patient was readmitted to Lenox Hill Hospital where a small abdominal incision revealed two masses, one above the liver and another one in the lower abdomen. Fluid reac¬ cumulated rapidly and the patient’s general condition became poor. On several occasions it was necessary to tap the subdiaphragmatic cyst and

Google

UNIVERSITY OF MICHIGAN

THERAPEUTIC

APPROACH

TO

CANCER

/

523

lower abdomen separately as emergency procedures because of acute dis¬ tress. Because analyses now showed a low pH (around 5.2) and low surface tension (around 61 dynes/centimeters), and also because she had obviously failed to respond to conjugated fatty acids, treatment with butanol and nonsaponifiable lipids of intestine was instituted. By July the situation ap¬ peared to have been brought under control again. Fluid was no longer

Fig. 191. Photomicrograph of a lymph node biopsied from patient M.B. showing metastatic adenocarcinoma.

accumulating and leg edema, which had been pronounced, was gone. At the end of 1954, no masses could be felt. The subjective complaints dis¬ appeared slowly. In February 1955, the nonsaponifiable medications were replaced by heptanol and octanol. The patient continued to improve with this treatment. In March, the abdomen was a a little swollen. By the end of April, a mass could be found in the abdomen just above the umbilicus. At the end of May the mass had increased and the patient was hospital¬ ized for about three weeks. A large bloody cyst was drained. A small lymph node was biopsied and microscopic examination showed the same meta¬ static adenocarcinoma. (Fig. 191) The patient was put on epichlorohydrin and the mass did not grow back. She has remained on epichlorohydrin

Digitized by GoOglC

UNIVERSITY OF MICHIGAN

524

/

RESEARCH

IN

P H Y S I O P ATHO L OO Y

and for four years has had no subjective discomfort. No mass can be felt in the abdomen and the patient is well now. Radiation and Chemotherapy Parallel to the guided chemotherapy, the idea of mixed radio- and chemotherapy has led us over the years to several tentatives. In one of them, in collaboration with Dr. L. Goldman on a larger scale, chemotherapy was added to radiotherapy. (Note 1) In spite of the interesting immediate re¬ sults, if chemotherapy was not further pursued, the ultimate fate of the patients thus treated was no better than that of the patients who had re¬ ceived radiation alone. Analysis of these various attempts has permitted us, however, to establish the conditions under which such a mixed treat¬ ment would appear especially indicated. Consequently, it is the type of offbalance present which is seen to determine the relationship between the two therapies, and respectively the procedure to be followed. The same relation has permitted to define the conditions under which chemotherapy would be indicated and added to radiotherapy. It should not be forgotten that through its action upon the fatty acids, radiation represents indirectly an agent of the same group to be added as the negative lipoids. The cases with a type A offbalance which seem to respond insufficiently to medication with agents, represent an indication for the mixed treatment. Acting in conjunction with radiation, chemotherapy has appeared especially active. Chemotherapy started before, is continued actively during radio¬ therapy and following radiation, for a long time, even for years. The radi¬ ation acting as an adjuvant agent is usually applied in small doses, from only several hundred r to a few thousand r, in general much below those dosages known to induce by themselves alone therapeutic effect upon tu¬ mors. In cases with type D, as the radiotherapy represents an agent in¬ creasing the actual offbalance, an added chemotherapy with positive lipoids would have the role of correcting not only the existing manifestations but of preventing some of those which would be induced by radiotherapy. It would in fact have the specific aim to permit the continuation of radio¬ therapy while limiting its noxious influence. The mixed therapy has to be guided by the routine test, with frequent analyses, in view of the rapid important changes which have been seen to occur. In these cases, it appears useful to follow especially the changes of the chloride index, those of peroxides in the urine which together with the surface tension, are seen to be not only particularly influenced by radiation but able to indicate the important change in offbalance.

Digitized b

Google

UNIVERSITY OF MICHIGAN

THERAPEUTIC

APPROACH

TO

CANCER

/

525

Exceptionally good results were seen in the cases in offbalance type A treated by this mixed method when chemotherapy has been added to radiotherapy. These cases are especially interesting because of the per¬ sistent result obtained. The abnormally small amount of radiation often used, applied only on a localized spot, has served in these cases as an adjuvant to help to resolve particular local problems, while the chemo¬ therapy, continued for a long time thereafter, to prevent the appearance of recurrences. In the case of offbalance D, as the radiotherapy will increase the actual offbalance and the role of chemotherapy is to reduce the intensity of this offbalance and thus permit the continuation of radiation for its direct target effect the results are less interesting, differing less than in the first case from those obtained by radiation alone. The continuation of chemotherapy how¬ ever after the radiation has been completed, has appeared especially helpful.

Level Chemotherapy In recent years, the course of our research has been directed parallel to¬ ward the precise application of available agents as well as finding new substances. For it has become increasingly evident to us that it is the basic independence of the different levels of organization in the body which rep¬ resents the critical factor in the pathogenesis of cancer and its manifesta¬ tions and which is also critical to the most effective use of therapeutic agents. This concept has led us to focus our research efforts in certain areas. Attempts are made to find criteria capable of indicating changes at specific levels of organization. Similarly, a growing awareness that each element belongs to a specific level of biological organization and exerts its bio¬ logical activity primarily at this level has led us to try to use specific elements in correcting dysfunctions at various levels. Because of the in¬ dependence of the levels, we have attempted to trigger the defense mecha¬ nism at appropriate individual levels rather than indiscriminately. This is especially important when the failure of the defense to operate at some one level represents a major factor in allowing pathological states to advance. While each of these developments has been important, it has been the use of all three which has brought marked progress in the clinical appli¬ cation of the method in the last years. With the concept of independence of levels, the use of more than one agent is not simply a matter of synergistic activity, but rather of employing several agents, each capable of acting at its proper level in complex con¬ ditions where more than one level is involved. To make this possible, it

Digitized b\

Google

UNIVERSITY OF MICHIGAN

526

/

RESEARCH

IN

P H Y S I O P A T H O L OG Y

has been necessary to relate analytical data to changes occurring at specific levels. For example, changes in potassium in serum and red cells have been related to cellular level abnormalities; urinary surface tension changes, to metazoic; specific gravity to systemic; urinary pH and blood eosinophiles, to tissular. This has guided the choice of agents: selenium preparations, epichlorohydrin and heptanol for the cellular level; sulfurized hydronaph¬ thalenes, lipoacids, unsaponifiable fractions and glycerol for the tissue level; magnesium and sodium thiosulfates, propionic aldehyde and butanol for the organ and organism levels. Through this approach, therapy has evolved toward what we can now consider to be biologically guided levelchemotherapy.

The following observations show the role of these level indications in the conduct of the treatment. F. R., in March of 1957, had a left mastectomy for an adenocarcinoma of a mammary gland. In July of 1958, she began to experience pain in the lower back and legs. In the three months prior to coming under our care, several skin nodules and some progressive difficulty in breathing was evi¬ dent and there was a loss of 25 lbs. in weight. On admission, multiple skin and subcutaneous lesions, some of them measuring 3-4 cm in diameter were found, as well as 3 or 4 nodules in the right breast. The ambulant patient started treatment with selenium and epichlorohydrin. Although treatment was followed with irregularity, improvement was seen in the local lesions. In December, 1959, however, the difficulty in breathing had markedly in¬ creased and oxygen administration was needed. In less than a week her condition worsened. The treatment with more selenium and epichlorohydrin appeared unable to control the situation. She was admitted to the hospital in extreme dyspnea. The suppression of oxygen for even a few minutes was followed by convulsions. Radiological examination showed a very limited exudate especially in the right hemithorax, but multiple matastases in both lungs. All the analyses showed an offbalance of type A. Considering the condition as manifested also at the organic and systemic level, to the treat¬ ment with epichlorohydrin, acting at the cellular level, we added bixine and propionic aldehyde. The first agent was considered to act at the tissular level and the latter at the systemic level. With this treatment the patient made a very good and constant recovery. In less than two weeks it became unnecessary to use oxygen and her general improvement progressed so that 3 months after treatment was started, the patient was able to resume part of her housework. With mixed treatment—epichlorohydrin acting at

Digitized b)

Google

original rrom

UNIVERSITY OF MICHIGAN

THERAPEUTIC

APPROACH

TO

CANCER

/

527

the cellular level, and bixine and propionic aldehyde at the organic and systemic level—the condition seems controlled. The pulmonary metastases seen in previous X-rays have also disappeared and all the skin nodules de¬ creased rapidly, most of them having completely disappeared. She is at present in good state of health, doing all her own housework. Mrs. C. H., 60 years old, came under our care two years ago with a history of lymphosarcoma with two positive biopsies of the inguinal glands, complaining especially of pain in the abdomen. On examination, inguinal, axillar and cervical glands were present, some of them 4 cm in diameter. With treatment of sodium thiosulfate and fatty acid hydropersulfides in relatively small doses, the pain was sufficiently controlled. After two months of treatment, the patient experienced extreme pain and a tumor of the head of the right humerus. In view of the local lesions with analyses which all showed an intensive offbalance of type A, the treatment was changed to epichlorohydrin and heptyldiselenide. Administering these agents in rela¬ tively high doses, it was possible to not only control the pain in a few hours, but to have the lesion disappear in less than two weeks, as did also all the abnormal glands. However, in spite of these objective very good results, the general condition became unsatisfactory, especially with marked weakness. Changes in the doses of medication or the temporary discontinuation of the medication, failed to correct it. It was only when propionic aldehyde con¬ sidered to act upon the organism level was administered, that a rapid change toward a feeling of general well-being was obtained. At present, with small doses of propionic aldehyde the patient is entirely free from any subjective or objective abnormal manifestations and has been so for almost a year. Mrs. E. R., 42 years old, had a radical mastectomy for an adenocar¬ cinoma of the breast. After 1 Vi years, she experienced persistent back pain which was first diagnosed as arthritis. X-ray studies and a myelogram made at Montefiore Hospital showed two metastatic lesions at the 1st and 2nd lumbar. Surgical intervention was thought to be not indicated. X-ray therapy neither relieved the pain nor made it possible for her to leave her bed. At admission under our care, the patient was in severe pain and unable to even turn in bed, although she was still able to move her legs and their sensitivity was conserved. A treatment with heptyldiselenide, propionic aldehyde and bixine made the pain disappear and up to date the patient is leading a normal life, after having been bedridden for 8 months. Mrs. M. McB., 62 years old, came under our care for a basocellular carcinoma of the left side of the face, near the inferior eyelid. Advised to

Digitized by

Google

UNIVERSITY OF MICHIGAN

528

/

RESEARCH

IN

P H Y S I O P A T H OL OGY

undergo surgery, which would enucleate the left eye, she refused the opera¬ tion. A biopsy was performed (Fig. 192) showing the presence of a basocellular carcinoma. She was treated with hexyldiselenide and with sodium thiosulfate, and the lesion disappeared within a few weeks. No recurrence was observed during the past 6 years.

Fig. 192. Photomicrograph

of the

biopsy

made

on

patient

M.McB.

showing

a

basocellular carcinoma.

Mr. G. Z., 56 years old came under our care for a lesion of the upper lip. Biopsy proved it to be a squamous cell carcinoma. (Fig. 193) The patient refused surgery or radiation which we advised. Following the biopsy the tumor started to grow rapidly, as seen in Fig. 194. According to the analyses, the patient was treated with fatty acid hydropersulfidc. The lesion disappeared in less than 2 weeks. (Fig. 195) No recurrence was observed although the patient was no longer under treatment. The patient died 8 months later from a coronary occlusion. The ability to induce changes at single specific levels has altered com¬ pletely what was once a gross dualistic approach. Until recently, we had considered it inadvisable to induce therapeutic changes at a single level if ofTbalances were present at more than one level. With the concept of level independence, it has become part of the method to attempt to influence

ed by

Google

UNIVERSITY OF

HIGAN

THERAPEUTIC

APPROACH

TO

CANCER

/

529

Fic. 193. Palicnt G.Z. before treatment.

Fig. 195. Patient G.Z. after treatment.

Digitized by

Original from UNIVERSITY OF MICHIGAN

530

/

RESEARCH

IN

P H Y S IO PA TH OLOO Y

the level in which the predominant abnormality is present rather than to induce gross changes at all levels. In cases with general offbalance A but predominant at the cellular level, therapy to induce offbalance D limited to the cellular level alone, with the metazoic remaining at offbalance A, has produced interesting objective clinical results. Similarly, good results have been obtained in cases with predominant offbalance D at the cellular level and in the metazoic compartment, with treatment directed at chang¬ ing the systemic and tissular offbalance D into type A without influencing the offbalance D at the cellular level. It is interesting to note that in both types of cases the changes lead ultimately to the same overall pattern of offbalance—D for the cellular level and A for the metazoic compartment. Level chemotherapy with selenium, heptanol, propionic adlehyde and other agents, has given highly gratifying results. It led us to the present form of treatment, with particularly good results. In a variety of tumors, some impressive because of their huge dimensions or because of their high de¬ gree of malignancy, the immediate objective response has been striking. Massive lung metastases from breast cancer, generalized abdominal metastases from colon carcinoma, bone metastases from breast or prostate, and metastatic melanoma are among the cases which have responded and we are now waiting for time to indicate whether the results have lasting value. While we were convinced in the past of the inherent potentiality of the method in general, because of results with many different agents and criteria, we have been greatly encouraged by the most recent applications. We believe the method now provides a means of controlling a significant proportion even of preterminal and terminal cases of malignancy consid¬ ered otherwise entirely beyond any hope. The particularly favorable results obtained in the cases which came under our care before the disease had progressed to advanced stages indicate that we are fully entitled to prefer this therapeutic method even for those cases where the presently used procedures might still have a chance to help.

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

CHAPTER

16 PRESENT FORM OF TREATMENT

T„e

therapeutic measures against cancer which have evolved thus far out of the pathogenic and pharmacodynamic concepts described in these pages have proved, as we have shown above, to be useful. All along in their development, they have fallen short of producing uniformly, the full measure of benefit which, we have continuously hoped, one day will be attained in most and possibly in all cases of malignancy. Yet the results achieved with biologically guided therapy, imperfect as they have been, have continuously indicated the great potential of the method. What has been accomplished during the years has been hardly consid¬ ered as a final measure of the effectiveness of this basic new approach to treatment but only of the available criteria and agents. With the criteria and agents the method itself has been evolving. In its present form, the method represents a valuable tool for helping many cancer patients who are entirely beyond help with present day methods. In spite of its accom¬ plishments further advances along the same lines—both in techniques for recognizing fundamental offbalances at different levels of organization and even in new compounds more effective in correcting them—are to be expected. Equal in importance with the current results with biologically guided therapy is the fact that new applications are evolving; that this approach helps us to better understanding and treatment of malignancy and of other pathological conditions as well; and that, by its very nature, the method has the capacity to furnish the guidance needed for improving it. We are presenting here the form of treatment which we currently use. 531

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

532

/

RESEARCH

IN

P H Y S I O P A T H OLOO Y

In this form, when correctly applied, biologically guided therapy can, in many cases, bring under control even far-advanced malignancies. The im¬ portance of the correct application of agents based upon specific criteria makes it necessary to emphasize how agents are chosen and used. Criteria Used: Recognition that no test is able to indicate by itself the

existence of more than an offbalance at a specific level, and that cancer is a complex condition involving many levels, has led to the use of a group of tests able to offer the necessary information on offbalances at different levels. We use the following routinely: Urinary—specific gravity pH surface tension calcium excretion index Blood— potassium in serum potassium in total blood Pain pattern Body temperature In exceptional instances when the routine tests do not suffice, we use: Urinary—chloride retention index Blood— chlorides in serum leucocytes count eosinophiles count The offbalance indications provided by these tests are shown in Table XXII. Table XXII

Test

Offbalance D

Specific gravity PH Surface tension Serum potassium Total blood potassium Body temperature Leucocytes Eosinophiles Chloride index Calcium index Chlorides in serum Pain pattern

high low low high low low low low high low high alkaline

_1— Digitized by VjOC >glt

Average Values 1.016 6.2 68 4.5 mEq 38 mEq 37°C 7000/c mm 100/cmm 2.1 2.5 525 mg %

Offbalance A low high high low high high high high low high low acid

Original from UNIVERSITY OF MICHIGAN

PRESENT

FORM

OF

TREATMENT

/

533

Whereas the other analyses give direct information concerning the offbalances, the values of potassium in serum have to be correlated with the values in red cells or in total blood potassium for a recognition of the offbalance present. A serum potassium above 4.5 mEq and a low total blood potassium below 38 mEq indicate an offbalance D, while a low serum potassium below 4.2 mEq with a high total blood potassium above 40 mEq, an offbalance A. Low values for both analyses indicate a quantita¬ tive deficiency of this element in general, while high values for both an excess of this element in the organism. As related to the different levels of the organization, specific gravity changes reflect processes taking place especially at the systemic level. The pH reveals, indirectly, changes at the tissue level. Surface tension indicates offbalances at the metazoic compartment; both serum and total blood potassium indicate cellular level offbalances. However, while potassium measurements give an indication of cytoplasm changes, calcium indicates cellular level changes, especially in the membranes. Eosinophile counts in¬ dicate acid-base changes at the tissue level, and temperature, systemic off¬ balances. As we have seen, any abnormal value is most likely to accurately re¬ flect a fundamental offbalance at its corresponding level when the same value is obtained in several repetitions of the test. Tests on two or three successive days are most helpful in ascertaining the existence of an offbal¬ ance, especially if it is limited to only a few levels. The offbalance determines which agents are to be used. As anti-A agents, we now use: propionic aldehyde epichlorohydrin hexyl or heptyl diselenide tetralin perselenide tetralin persulfide sodium or magnesium thiosulfate mixture of lipoacids As anti-D agents, we use: heptanol polyunsaturated alcohols butanol glycerol insaponifiable fraction of liver glycerophosphoric acid

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

534

/

RESEARCH

IN

P HYS I OP AT H OLOGY

The preparations and usual doses are: Propionic adlehyde: 10% sol.—for oral administration, used from 501000 mgr. daily; for parenteral administration: 2% sol. in saline. Epichlorohydrin: 0.5% solution in isotonic saline, used from 1/10 mgr. to hundreds of milligrams daily for parenteral and oral administration. Hexyl or heptyl diselenide: in solutions from 20 micrograms to 50 mgr./cc. for intramuscular injection. Orally, we use either capsules con¬ taining from 10 micrograms to 10 mgr. or, still better, a solution of 0.4% in oil, which corresponds to 100 micrograms per drop. The doses vary from 10 micrograms to 50 mgr. or more daily. Tetralin perselenide: This preparation has 40 mgr. of selenium for 100 gr. of tetralin and is used orally as drops, from a solution of 10% or 1 % in oil. For injections, a solution containing 10% in 100 cc. of sesame oil, is used in doses ranging from 0.1 cc. to 10 cc. daily. Instead of tetraline, naphthalene or other aromatic hydrocarbons are used. One cc. of a 10% solution of these preparations in oil, contains 0.1 mg. of selenium; the doses used range from 0.1 cc. to 10 cc. daily. Sodium or magnesium thiosulfate is used in a 10% solution for oral administration or in a 4% solution for intramuscular injection in doses ranging from 25 mgr. to 5 grams or more daily. Tetraline persulfide: This preparation contains 5% sulfur in oil and is used orally from %0 cc. to more than 10 cc. daily. In intramuscular injec¬ tions it is used from Vio cc. to 2 cc. daily. The acid lipids mixture is a solution in oil of 1% bixin, 2% cow liver lipoacids and 7% cod liver oil fatty acids. It is administered in doses of from Vi cc. to 6 cc. daily by intramuscular injection. Heptanol in a solution of 0.5% or 5% in oil is used for parenteral administration; a solution of 5% in oil is employed for oral administra¬ tion. The doses range from 1 mg. to hundreds of mgs. a day. Polyunsaturated alcohols are safflower oil fatty acids with the carboxyl changed to a primary alcohol. They are used in a 10% solution in oil with Va to 2 cc. injected intramuscularly up to four times a day.

Butanol in a 6.5% water solution is used for oral administration. A 6.5% saline solution is employed for parenteral administration. Usual doses are from Va cc. to more than 100 cc. daily. Glycerol is used as a 50% solution for oral administration or as a 20% solution for parenteral administration in doses ranging from less than 0.2 gram to a few grams daily. Insaponifiable fraction of pork liver in a 5% solution in oil is used for intramuscular injections in doses from Vi cc. to 8 cc. daily.

Digitized by

Goo

UNIVERSITY OF MICHIGAN

PRESENT

FORM

OF

TREATMENT

/

535

A preparation of a mixture of polyunsaturated alcohol, heptanol and butanol also is used for oral or parenteral administration. If, during treatment, any other medications appear necessary for vari¬ ous concomitant conditions, it is preferable to choose them with consider¬ ation given to the influence they will exert upon the patterns present. Table XXIII shows the effects of some commonly used therapeutic agents upon the fundamental offbalances, which would indicate their use in cases with one or the other offbalance.

Table XXIII Effects Upon Offbalances A and D of Various Agents Used Therapeutically

Having an anti A effect

Dicoumarol Digitalis Antipyrine Aminopyrine Acetophenetidine Atropine Quinine

Having an anti D effect

Glycerol Glucose Coramine Acetyl salicylic acid

Caffeine

Procaine Codeine Morphine Demerol Aminophylline

Liver extracts Vit. A, D, B.

Iron Vit. B„ B„ K. E

Testosterone

Progesterone Stilbesterol Desoxycorticosterone Glucosamine

Epinephrine Penicillin Streptomycin Aureomycin

Cortisone

Sulfas

Insulin Barbiturates Mercuhydrine Benzedrine Benadryl

Original from Digitized by GOOglC

UNIVERSITY OF MICHIGAN

536

/

RESEARCH

IN

P H Y S I OP A T H OL OO Y

In using the various agents, we have to keep in mind the effect upon the existing offbalances. Conduct of Treatment: Although there may be some variations depend¬

ing upon the circumstances of individual cases, treatment is conducted generally as follows: Urine and blood analyses are performed. Values for two or three con¬ secutive days are usually determined before starting treatment. If all values indicate the same pattern, the diagnosis of the offbalance is clear. If the analyses indicate the presence of different patterns, an interpretation is made on the basis of analyses showing the offbalance at specific levels. For patients in whom manifestations involve the metazoic compartment, uri¬ nary surface tension is the important criterion. Urinary specific gravity and urinary pH, are important when systemic or tissular manifestations are present. Potassium is the criterion when changes at the cellular level are most important. The body temperature and the other complementary anal¬ yses are used when discordant patterns are encountered. They help to rec¬ ognize the type of offbalance at the different corresponding levels. Once the level offbalances are determined, suitable treatment is in¬ stituted. The agent is chosen from the proper group according to the level

Table XXIV Agents Chosen According to the Tests 1

Agents

1

Level Cellular

Tissue

Test Potassium in blood 1 Urinary calcium Urinary pH Blood eosinophiles Surface Tension Pain pattern

Offbalance

A

Selenium preparations Epichlorohydrin

Heptanol

Lipoacids Tetralin persulfides Hydropersulfides Mg Thiosulfate

Polyunsaturated alcohols Unsaponifiable fraction liver Glycerol Butanol

Organ and Urine specific Mg or Na Thiosulfate Organism gravity Propionic aldehyde Surface Tension Body temperature

Digitized by

Google

Offbalance D

Glycerophosphoric or lactic acid

Original from UNIVERSITY OF MICHIGAN

PRESENT

FORM

OF

TREATMENT

/

537

to be influenced. Since, in invasive cancer, the offbalance occurs at the cellular level, the agents used are selenium preparations and epichlorohydrin, for the offbalance A and heptanol for the offbalance D. For the tissue level, indicated by pain as well as by urinary pH or eosinophiles, lipoacid preparations. Mg thiosulfate and Tetralinpersulfides are used for offbalance A, and polyunsaturated alcohols, unsaponifiable fractions and glycerol and butanol for offbalance D. For the organ and systemic levels, with the offbalance recognized through urinary specific gravity, surface tension and body temperature, magnesium or sodium thiosulfate and propionic aldehyde are used for offbalance A, and glycerophosphoric acid for offbalance D. (Table XXIV) Conduct of Treatment

If the patterns of the different tests and clinical manifestations are con¬ cordant, concerning the offbalance present, the agents chosen are from the respective group. Special attention is given however to the level which, clinically or analytically, shows the most abnormality, so that for a patient with a limited tumor, but without pain and in good general condition, the factor guiding the therapy will be the analyses related to the cellular level (as revealed by the potassium in blood). If the general condition is poor, indicating rather a predominant systemic condition, the treatment will be directed especially by the abnormalcy at the organism level revealed by the corresponding analytical tests—such as urinary specific gravity, surface tension and body temperature. This interpretation of the most needed intervention becomes still more important when the data obtained—clinical and analytical are discordant. The treatment will follow the indication furnished by the level which appears the most important. In a case with a limited tumor, and no other clinical manifestations, the pattern of the cellular level, will determine the nature of the treatment, even if the other analyses show different patterns. For a patient with a tumor and severe pain—it is the pattern of the pain which will indicate the agent to be used—even if this is discordant with that of other analyses. The same is true for a systemic severe condition, the respective analyses determine the agent to be used, even if these are dis¬ cordant with the analyses concerning the other levels. In general, the de¬ cision of what level will represent the guiding factor in the treatment, represents seldom a problem, the condition of the patient directing the atten¬ tion toward the principal anomaly. In general, treatment is started with small doses. If the offbalances, and especially the clinical manifestations persist, increased doses are indi-

Diqitized b

Google

UNIVERSITY OF MICHIGAN

538

/

RESEARCH

IN

P H Y SI OP A THO L OG Y

cated. Larger amounts are used and are administered more often. Once the desired analytical and clinical effect is obtained, dosage is maintained. If analyses corresponding to the offbalance pass far enough on the opposite side, the amount of the medication is first reduced. If this change persists or increases, treatment is discontinued for several days. If the new offbalance still persists, and especially if new clinical symptoms develop, use of the opposite group of agents is to be considered. A slight passage of an offbal¬ ance into the opposite is usually salutary and treatment is continued as long as clinical improvement persists. It appears to be of great importance that treatment be continued for several months after all subjective and objective manifestations have dis¬ appeared. In a number of patients, we have been investigating the value of continuing medication for years in very small doses as a prophylactic meas¬ ure to prevent recurrences. The results have been highly encouraging. No inconveniences have been noted with controlled continued use of any of the substances. Results obtained

With this form of treatment most of the results obtained are striking. With naphthalene or tetrahydronaphthalene perselenide, epichlorohydrin and bixine as principal agents for the type A and heptanol-glycerol for the type D, the subjective and objective manifestations were seen to be well con¬ trolled. Pain, if present, disappeared in a few days, the tumors progressively diminishing until they disappear, even in cases considered as far advanced. The following few recent observations of such cases, give an idea of these results, up to date. Mrs. M. C., 59 years old, had 3 years ago a mastectomy for adeno¬ carcinoma. She came under our care with metastases in the right 8th rib and in the 11th and 12th dorsal vertebrae, liver metastases, ascites and pleural effusion. With dyspnea, severe pains and almost continuous vomit¬ ing, her general condition was judged very poor. Paracentesis was per¬ formed, but the fluid accumulated rapidly, needing a second paracentesis 10 days later. In offbalance A, the patient was treated with perselenide, bixine propanal and epichlorohydrin. Shortly after the beginning of the treatment, the pain decreased in intensity and later disappeared completely. The pleural effusion decreased and after the two paracentesis, the ascites no longer reproduced. The general condition changed rapidly for the best, together with the objective changes. Liver reduced in size after three months of treatment was within the normal limits. Radiological examination, two months later showed the bone metastases completely healed. The general

Diqitized b

Google

UNIVERSITY OF MICHIGAN

PRESENT

FORM

OF

TREATMENT

/

539

condition continued to improve. The patient resumed her normal life and now does not show any clinical abnormality. Mr. J. S., 71 years old. Two years prior to admission, the patient had persistent hematuria, for which a prostatectomy was performed. Hematuria reappeared. Cystoscopic examination revealed tumors of the bladder, for which he was operated 1 Vi years ago. Since then, he has had almost con¬ stant hematuria, with frequent micturitions during the night and almost every hour during the day. Pain in the lower abdomen became progressively stronger. The patient was admitted and treated, in accordance with the analyses, with perselenide, bixine and epichlorohydrin. In less than a week, the hematuria disappeared, as did the dysuria, the patient being able to pass clear urine every 6 to 8 hours. With the interruption of the treatment for almost a month, the symptoms reappeared, with hematuria and dysuria. With the treatment resumed, the condition responded well again, the hema¬ turia and dysuria being controlled and pain disappeared. Mrs. R. A., for five years, had symptoms of gastric ulcers, more ac¬ centuated in the summer, which improved with treatments. For six months prior to coming under our care, the patient had progressively marked diffi¬ culty in swallowing anything other than fluids. Even after taking fluids, she experienced very severe retrosternal pain, almost always followed by vomit¬ ing. X-ray examination showed slight dilatation of the esophagus with a clearly visible growth in the stomach near the cardia. According to the anal¬ yses, the patient was treated with perselenide in injection, and bixin and epichlorohydrine orally. Two weeks after treatment was started, the patient was able to swallow not only fluids but also finely ground food. The im¬ provement continued, the patient being able after 5 weeks of treatment to swallow food of almost normal consistency. Mr. J. R., 56 years old, came under our care with severe pains in the right side of the neck and hemoptoic sputum. At examination, a submaxillar gland of 6 cm. diameter was seen. Laryngoscopic examination showed a tumor in the right pyriform fossa—Biopsy revealed a squamous cell car¬ cinoma. The very severe and constant pain and the constant bleeding caused the patient to be hospitalized. According to the analyses, perselenide by injection, epichlorohydrin and bixine were administered. In 24 hours the pain was fully controlled. The bleeding stopped after 4 days, and the gland started to decrease—10 days after the beginning of the treatment. The laryngoscopic examination showed the tumor tranformed into a graying mass, which was progressively decreasing. Mrs. A. D., 60 years old, admitted to the hospital with dyspnea, cough and pain in the right hypochondrium, epigastrium and generalized weak-

Google

UNIVERSITY OF MICHIGAN

540

/

RESEARCH

IN

PHYSIOPATHOLOGY

ness. For 30 years, the patient had complained of pain in the right hypochonder, related to the presence of gall bladder stones. In February of 1960, a laparatomy was performed and a tumor of the gall bladder with metastases to liver was found. Only a biopsy was performed which showed a carcinoma. At admission under our care, the patient was in very poor general condition with marked dyspnea, deep jaundice and severe pains in the upper abdomen, emaciated. A right pleural effusion was found and a thoracentesis performed. An irregular mass was found in the right hypochondrium arriving until the umbilicus. She had clay colored stools, typical for obstructive jaundice. In spite of thoracentesis the dyspnea continued to be severe and the patient was kept under oxygen. The patient was placed under chemotherapeutic treatment with epichlorohydrin, bixine and perselenide in accordance with her urinalyses. The patient’s condition improved progressively. The stool returned to normal color; fluid in the right chest did not reproduce and the mass on the right hypochondrium decreased progressively to have the liver in normal dimensions. At present, the patient with all the subjective and objective symptoms improved considerably, is ambulatory. Mr. S. S., 64 years old, was operated in 1953 for a hypernephroma of the right kidney. Two years later, massive metastases were seen in the left femur and pelvic bones. Pathological fracture of the neck of the left femur was treated surgically. Further X-ray examinations revealed extensive metastases of the femura, and pelvic bones, with multiple lung metastases. When the patient came under our care, he was suffering agonizing pain especially in the left hip. An X-ray examination showed an almost complete disappearance of the upper part of the left femur, with multiple metastases in the right femur and pelvic bones, and multiple metastases in both lungs. According to the analyses, the patient was treated with perselenide, bixine, and epichlorohydrin. The condition improved rapidly, the patient being able to sit up and even to walk a little. He was discharged from the hospital to follow the treatment at home which was done very irregularly. He was readmitted a month later with very severe pain and the treatment resumed. The pain subsided gradually and the general condition improved markedly. Recent X-rays revealed a manifest recalcification of the upper part of the left femur which, in previous X-ray examinations, had no longer been visi¬ ble. At the same time, many of the metastatic lesions of the lung disappeared while in others, a marked decrease in their size was seen. These subjective and objective improvements are continuing constantly, up to date. F. G., 61 year old female, in July 1960 had partial cecostomy for adenocarcinoma. The mesenteric lymph nodes were found involved. A

Digitized by

Google

UNIVERSITY OF MICHIGAN

PRESENT

FORM

OF

TREATMENT

/

541

month later, because of vaginal bleeding and an erosion of the cervix, a biopsy was performed, showing the same malignancy. With constant bleed¬ ing and pain in the abdomen, the patient came under our care. On examina¬ tion the tumor was seen to occupy all the upper part of the vagina, with infiltration of the recto-vaginal wall. According to the analyses, a treatment with perselenide in injection, epichlorohydrin and bixine was instituted. The bleeding stopped completely after one week, as did the pain. While the patient is still under treatment, the lesion has been seen to regress constantly, up to date. W. M., 48 year old male. In 1956 he had a left nephrectomy for hypernephroma. He was well until early in 1960 when a mass was found in the left side of the abdomen which was progressively growing. At the same time, he had hemoptoic sputum. The x-ray examination of the chest showed multiple lung metastases. Five weeks before coming under our care, a very marked edema of the left leg with very severe pain in the back and leg appeared. He came under our care especially for the unbearable pain. According to the analyses, a treatment with heptanol, butanol and glycerol was instituted. The pain disappeared in 2-3 days and has not returned in the two months which have elapsed since then. The edema of the leg also disappeared. The tumor which, at the time of administration, was occupying the entire space between the ribs and the ileac crust, was seen to become first much softer, and progressively to reduce its dimension. Actually two months after the treatment was started, the patient is leading a normal life with the tumor decreasing progressively. We want to emphasize that benefits, often impressive even in terminal cases, have been obtained only by following the above rules. Treatment guided closely by changes observed in the patterns indicated by analyses appears to be the condition sine qua non for the attainment of good results. The results obtained and especially their high proportion, even in far advanced cases, permits a fair judgement of the place of the present form of application of this method in the fight against cancer. Based on these results, we are fully entitled to consider it, not only a highly beneficial treatment which can be offered now for this disease, but even a major step nearer to the solution of the problem of the therapy of cancer.

Digitized by

Google

Original from UNIVERSITY OF MICHIGAN

Digitized by

Google

Original from UNIVERSITY OF MICHIGAN

NOTES

Chapter 1, Note 1. Subnuclear Organization The analysis of the available data concerning subnuclear particles shows that while an unsuspected number of different particles are progressively discovered, no satisfactory relationship between them—from the point of view of the organization—can be established. The recognition of a pattern concerning their organizational relationship would fill an important gap in the knowledge of this entire field. The fact that the same pattern governs the organization in general, from atomic nuclei up, has induced us to attempt through an extrapolation, to search it for the subnuclear realm. As seen above, the study of the organization has permitted us to define the following concepts as characteristic for the organizational pattern: 1) All the entities in nature can be identified by their place in a hierarchic organization, in which the entities are connected through a superior-inferior relationship. An entity enters in the formation of other entities which are considered “superior” to it, and is formed by entities which are hierarchically “inferior” to it. 2) Each entity is formed by a principal and a secondary part, the principal part being represented by entities hierarchically inferior to it, while the secondary part, by elements taken from the immediate environ¬ ment in which the entities forming the principal part have existed. 3) Entities with similar principal parts belong to a same level. In the hierarchic progression, there are entities of the same level which are grouped together to constitute the principal part of an entity of a level immediately superior. 4) From the energetic point of view, the principal part in the organiza¬ tion of each entity appears more positive than the secondary part to which it is bound. 5) The hierarchic progression of the organization from one entity to that immediately superior to it, is made through two processes with two different intervening forces. Forces of Columbian nature bring and keep the electrostatically opposite principal and secondary parts together. A new entity appears however only when quantum forces intervene, organiz¬ ing the relationship of the two constituents and especially their reciprocal movement. The immediate aim of this organization is to prevent a re¬ ciprocal total annihilation of the two parts, positive principal and negative secondary which would occur if the electrostatic forces alone would be present. 6) In the hierarchic progressive development of the organization for 543

Digitized b}

Google

nnama from

UNIVERSITY OF MICHIGAN

544

/

RESEARCH

IN

P H Y S I O P A T H OL OOY

each passage from one level to the immediately superior, these two kinds of forces—electrostatic and quantum—were seen to intervene alternatively. The fulfillment of one force is seen to induce the appearance of the other. From an energetic point of view, an entity will appear inactive when its electro¬ static forces are fulfilled but with quantum forces present, or energetically active with quantum forces fulfilled and the electrostatic forces present. The example of atoms and ions is a typical illustration of this relationship for the atom level. As a work hypothesis, we tried to apply the above schematically presented concept of hierarchic organization, to the subnuclear realm. It is only* by using analogies that such an attempt can be made. The scarce data available seem to confirm however, this view. According to it, the electron and positron would represent the lowest entities of the subnuclear realm with the smallest mass and opposite charge. If these two corpuscles, when attracted, encounter one another, they will annihilate each other with liberation of two photons. This annihilation is prevented however, although the two corpuscles remain bound together through their electro¬ static forces by the intervention of quantum forces organizing their re¬ ciprocal movements. The result is a new entity, of a level immediately superior to the positron, in which the electron is kept electrostatically bound to the positron but kept into an orbital movement. Hypothetically, it can even be conceived that through differences in the resulting movement, more than one solution would exist. Residual Charge

Due to the intervention of this movement, the resulting electrostatic neutralization between positron and electron is incomplete. A “residual” positive charge would characterize the new entity. This charge alone would not be sufficient to keep another electron by neutralizing its charge. How¬ ever several such entities grouped together can have the sum of their “residual positive charge” such as to be compensated by a new electron. The two electrostatic forces, that of the group of entities and that of the new electron will keep these two parts together, while the quantum forces will again organize the movement of this new added electron, preventing this time again the annihilation of these two parts. A new level, this time of the third order, is thus realized. It is easy to conceive that several solutions can exist for each case, since the sum of the residual positive charges does not correspond exactly to that of the negative electrons. Several solutions appear thus possible. Besides this in which a small group of entities would be compensated by one electron, a higher number of entities would be kept together with the sum of their residual charges approaching that of two or more electrons. For each level, several such solutions are conceivable. With the progressive passage toward higher levels, the number of the solu¬ tions increases. The fact that the two electrostatic positive and negative parts of the entities do not compensate perfectly, leads to the possibility that the com¬ pensation takes place either with an excess or lack of negative charge.

Google

UNIVERSITY OF MICHIGA

NOTES

/

545

The difference is induced by an additional electron. An entity with a positive or negative charge would result. With one or the other charge pre¬ vailing, two energetically active, positive or negative forms, differing by the mass of an electron exist, for each entity. The analysis confirms this ex¬ istence. According to the hierarchic organization, the different particles of the subnuclear realm can be separated in various levels. Promezons, mezons, protons would represent such levels—each one with respective neutral, positive and negative entities. The same as for the higher levels—atoms and molecules—the different entities forming each of the subnuclear levels will differ through the number of the entities entering in the principal parts. A systematization of the subnuclear realm on this basis can be confirmed by the fact that the different entities of a level represent sums or multiples of the entities of their inferior level in the same way that the different nuclei represent multiples of entities of the protonic level protons and neutrons or the different molecule multiple of entities of the atomic level. In the progression of the hierarchic organization, it is seen that the passage from one level to the other results in an exponential increase in the numbers of the kinds of entities (from around 100 different atoms it passes to around 100,000 different kinds of molecules, to millions of kinds of genes and trillions of individuals. This fact supposes that the number of the existing particles decrease with each inferior level, in the subnuclear realm, to arrive to two—positron and electron—at the bottom of this realm. Chapter 2, Note 1. C-N-C-N As far back as 1905, Kossel has had indicated the existence for the important alkaline aminoacids, arginine and histidine, of the C-N-C-N group, found also in the nitrogen containing bases of nucleic acid. The hypothesis which we advance that this C-N-C-N group would represent the starting point of the biological realm itself, can surely be subject to discus¬ sion. Progressively more evidence is being obtained that important organic compounds can appear from the constituents of the atmosphere itself, under the influence of electrical discharges or of ionizing irradiation. While Henriet (268) was the first to show that formic acid is present in rainwater, it was Loew (269) who obtained glycine from the constituents of the atmosphere submitted to electrical discharges. By utilizing, under the same condition, mixtures similar to those considered to have been present at the time when life is supposed to have started, Miller obtained, through elec¬ trical discharges, many amino acids and other substances especially glycine and formic acid (270, 271). Miller’s results were extensively confirmed (272 to 279). The irradiation of the mixtures of gases considered present in the at¬ mosphere millions of years ago has led to the synthesis of many other sub¬ stances such as formic, acetic, propionic, succinic and even tricarboxilic acids (280, 287). From these, we consider of especial importance the

Google

UNIVERSITY OF MICHIGAN

546

/

RESBARCH

IN

PHYSIOPATHOLOOY

members with a second nitrogen group far in the molecule, as diaminosuccinic acid, iminodiacetic or iminoacetic-propionic acid. The synthesis of the strongly positive C-N-C-N group which we con¬ sider as the starting point of the biological realm, seems thus to have taken place rather under the influence of radiation. This fact appears especially important since it would relate more directly the beginning of the biological realm to the intervention of the radioactive elements, which according to our systematization of the elements, form the period which corresponds to the lowest levels of the hierarchic organization. (See Chapters 2 and 5) ALKALI* AH I NO-AC IDS

NITROGENOUS BASES

Arginine PyrlildlnM

Adenine

Thyaint

HUtidlnt

COOH Guanine

Cytosine

H

Fig. 201. The NHa and C-N-C-N groups appear as entities taking part in the forma¬ tion of alkaline amino-acids as well as of nitrogenous bases. The bond to a chain having an amino acid group in the first case, results in a new entity—an alkaline amino acid—which polymerizes through the amino-acid group. Through the alkaline group it conserves its positive electrical character. In the nitrogenous bases, the C-N-C-N group is part of the cycle. Bound to phosphoric acid, the results are acid entities with negative charges.

The further evolution of the C-N-C-N formation seems to have taken

place in two directions—one in which one or two such groups have formed a cycle and given rise to the nitrogenous bases, purines and pyrimidines, and the other in which this energetic group has bound an aliphatic amino acid chain, this last probably originated under the influence of electrical dis¬ charges. The two principal alkaline amino acids, arginine and histidine, have thus appeared. (Fig. 201) The double capacity of the alkaline aminoacids, to bond other amino-acids through their amino-acid groups and thus to form polymers, and to bond acid substances through their alkaline polar groups and make new hierarchic entities, has given these substances their peculiar organizational role. C-N-C-N, alkaline amino-acids and histones

Digitized by

Goo

Onginal from UNIVERSITY OF MICHIGAN

NOTES

/

547

(or in fish, the protamins) would thus represent the first hierarchic steps in the progression of the biological series. A few words should be said about lysine, the alkaline amino-acid with an amino group as alkaline terminal group. Although together with the other alkaline amino-acids, it enters in the formation of histones, it seems to have another important biological role, that of an agent intervening in the metabolism of lipids. Chapter 2, Note 2. Distribution of Potassium and Sodium As mentioned above, potassium is the cation of the cytoplasm, the secondary part of cells, while sodium is the cation of the secondary part of the metazoic compartment, that is of the fluids of this compartment. According to the view presented above, the peculiar distribution of these two cations in the biological realm results from their similar distribution in the environments from which these respective secondary parts, cellular and metazoic, are considered to have been derived. As we related the cytoplasm to mud, respectively to the lithosphere, and the fluids of the metazoic compartment to the sea, we looked for a confirmation of this view in the comparison between the amount of these cations in the two biological compartments and in the two environments which we consider to cor¬ respond to them. Although potassium and sodium are in almost equal amounts in the general constitution of the earth’s crust, potassium is found almost entirely in the solid parts while sodium forms the principal constituent of the salts of the fluid part of the earth. The distribution of potassium found between cells and extracellular fluids seems very near to that which exists between lithosphere and hydrosphere. Potassium is found in a proportion of 2.46% of the lithosphere and only in 0.04% of the hydrosphere (201). The ratio of these respective concentrations corresponds to a % i value. This seems near enough to the ratio found in biology. While the extracellular potassium represents only 5 mEq per liter, with a total of 70 mEq (2.7 gm.) for a normal body, the intracellular part corresponds to 115 mEq per liter of cells, with a total of 4,000 mEq (160 gm.) for the body (202). The ratio of y5o for total extracellular and intracellular is accepted today although generally considered too high when compared with the previous data given years ago by Shohl (265). This value of Vs» appears impressively near the ratio of %i found in the comparison of the potassium content of the lithosphere with that of the hydrosphere. A similar resemblance is encountered when comparing the proportion between sodium and potassium in two fluids: the interstitial fluid of the body and of the sea. The two ratios of these elements appear close enough. For instance, the Atlantic Ocean has 10.464 gm. of sodium per thousand and 0.725 gr. per thousand of potassium, while the Pacific Ocean has 10.233 gr. per thousand of sodium and 0.634 gr. per thousand of sodium (266). The ratios between sodium and potassium are respectively 14 and 16. In the blood serum, the ratio is 16 when the average is considered as

Google

UNIVERSITY OF MICHIGAN

548

/

RESEARCH

IN

PHYSIOPATHOLOOY

320 mg.% of Na, and 20 mg.% of K. Table XXV shows these compara¬ tive values. Table XXV

(a) Comparison between the Extracellular and Intracellular Potassium and the amount present in Hydrosphere and Lithosphere. Ratio Potassium Potassium Potassium Potassium

extracellular-total body intracellular-total body in the hydrosphere in the lithosphere

2.7 gm. 160 gm. 0.04% 2.46%

) ) ) )

1/59 1/61

(b) Potassium and Sodium in the sea and in the body fluids. Na Atlantic Ocean Pacific Ocean Blood Serum

10.464 gr. 0/00 10.233 gr. 0/00 320 mgr. 0/0

K

Ratio

0.725 gr. 0/00 0.634 gr. 0/00 20 mgr. 0/0

14.4 16.0 16.0

These values seem to bind the distribution of K and Na, seen between the cellular and metazoic compartments, to that which exists between the environments from which we consider these respective secondary parts to have been derived. Chapter 2, Note 3. Social Hierarchic Organization The organization of nature with the characteristic hierarchic structure so evident in the biological realm, has suggested a similar structure in social organization. All the factors which were seen to characterize hierarchic organization appear clearly in an analysis of social organization. (Fig. 202) The entity, immediately above that of the individual, is the family. Here, parents and children—as a grouping of entities of the same level form the principal part. The secondary part is made up of elements of the immediate environ¬ ment, which are kept organized around this principal part, and as such are integrated in the new entity, the family. Housing, goods, even psychological factors, ideas and habits, characterize these added factors. A boundary formation is often much more visible than expected. Living quarters and common possessions are well delineated, and characterize the family. As expected, most of them are not considered to belong to an individual but the family as entity. “This is family property” is a common expression. Almost always, numerous families are grouped in nearby dwellings, although this fact alone does not lead to the immediate superior entity, the community. When the group of families organizes together and limits cer¬ tain possessions taken from the environment, as common to the group, the entity “community” appears. The principal part is made up of the group of families, the secondary by the material and even moral goods which are attached to the group of families in common. The community has prop-

Digitized b;

Google

Original from UNIVERSITY OF MICHIGAN

NOTES

/

549

cities which belong only to the community—streets, for example—as it has, by definition, a boundary. The limits of these social entities are well defined and these three factors—principal part, secondary added part from the environment and boundary—characterize these entities as they char¬ acterize the entities in the entire biological realm. The same pattern applies for the county where groups of communities form the principal part, and

Individuals' Goods— Families' Goods — Communities' Goods'^ Counties' Goods

Counties

States' Goods

Nation's Goods

Individuals -Families s Communities

-States

4-\-v—

International Goods -

Nations Human Society

Fio. 202. The social hierarchic organization follows the same pattern as the organi¬ zation of matter or of the biological realm. Each entity results from the bond of a group of lower entities with a secondary part taken from the environment and limited by a proper boundary.

proper parts taken from the environment and common only to this new entity form the secondary part. This entity also is defined through its boundary. It is easy to see how through the same hierarchic pattern we pass from counties to states, nations, hemispheres and world which repre¬ sent successively higher hierarchic entities. It is interesting to see how, in each one of these social entities, the same manifestations which we have found to characterize the biological entities also exist. The relationship between entities and especially many of their functions shows that the

Digitized by

Google

Original from UNIVERSITY OF MICHIGAN

550

/

RESEARCH

IN

PHY S IO P A TH OLOG Y

social entities are not artificial mental concepts, but are the result of the intervention of the same forces in which heterotropic organization opposes the lawless homotropy. It has appeared interesting to see how much of the knowledge of the physiological and especially the pathological manifesta¬ tions of the lower entities, we can apply to understand manifestations oc¬ curring at the social hierarchic levels. Under this aspect, sociology finds a new basis not only for the analysis of many of its problems, but can have an insight to how nature, through its own organization, has tried and often succeeded in resolving problems. With the concept of unity in all organization, from subatomic to social entities, we can understand how the evolution of the environment, repre¬ sented by material and intellectual goods, can produce changes in social entities. The concept of higher social entities, organized so as to conserve the characteristics of the lowest social entities, gives a new aspect to the relationship between individual, family and society. A science of social physiology can be created by systematizing hierarchic social entities much as we did for entities in the biological realm. The same approach can be applied to social pathology and social therapy as well. Such an approach, will be the subject of other presentations. Chapter 3, Note 1. Precancerous Lesions Precancerous lesions were identified especially in cases in which cancer¬ ous lesions were induced and where a manifest polycentricity of lesions was present. (203) Polycentric lesions permit us to study the entire successive changes from normal to invasive cancer. Induction of cancer in the stomach of rats through carcinogens and detergents (204) has furnished excellent material for such study; it has also permitted us to characterize the specific changes. Among cells which appear grossly normal, there are some in which certain morphological char¬ acteristics of the nucleus, notably size and form, appear abnormal. The existence of an anomaly is much more evident when the cell divides. It may be limited to just a few chromosomes which are abnormal in their dimension and form. This chromosomial abnormality appears still more evident when compared to cells in mitosis in controls with normal mucous membranes. (309) Chapter 3, Note 2. Non-invasive Cancer We have emphasized the character of the cytoplasm of the cells in non-invasive cancer. The nuclei show a number of changes which, together rather than separately characterize a cancerous entity: an irregular shape of the nucleus with a manifest increase in size; a sharp nuclear border formed by a dark pigmented nuclear membrane having fine chromatine particles; a hyperchromatism with clumps of chromatin separated in bizarre, irregular fashion; and an uneven, irregular distribution of these chromatin clumps, concentrated near the nuclear membrane. Also often

Google

UNIVERSITY OF MICHIGAN

NOTES

/

551

encountered is the presence of one or more irregular enlarged nucleoli, with a distinct nucleolar border and especially with a manifest acidophilic stain¬ ing. In the non-invasive cancer, all these nuclear anomalies contrast with the relatively normal cytoplasm, which has not only an acidophilic reaction —colored in orange with Papanicolau’s trichromic staining—but also a well-defined cell membrane with fairly clear cell border. The size of the cytoplasm—compared to other cells—is normal, although the nuclearcytoplasmic ratio is increased due to the big nucleus. Due to the character of the cytoplasm, these cells were called the “third type differentiated cells” by Graham. (205) We emphasized the “normal” aspect of the cytoplasm of these non-invasive cells, in contrast to the invasive cells where the ab¬ normality includes both the nucleus and the cytoplasm. This explains why most of the invasive cells have little cytoplasm, an indistinct cellular border and a basophil cytoplasmic staining. (206) But besides these cells with totally abnormal cytoplasm, there are some invasive cells with an apparently differentiated cytoplasm. Although their staining is orthochromatic, their cytoplasm shows marked abnormality in form. The tadpole cells found in the exfoliative cytology in epidermoid carcinoma, (207) or the fiber cells (208) with abnormally long fibrillar cytoplasm revealed in other forms of invasive cancer indicate a participation of the cytoplasm in the abnormal¬ ity. The cells found in so-called “Bukhead’s disease” with minimal ab¬ normal cytoplasm thus appears to be at the boundary between non-invasive and invasive cancerous cells. Chapter 3, Note 3. Abnormal Amino Acids We have seen above how the concept of hierarchic organization brought us to consider the alkaline amino acids and the histones which they form as one of the first members of the biological realm. Anomalies can be con¬ ceived to result from a process of resonance which occurs constantly on a statistical basis. As work hypothesis, we consider such resonance entities as corresponding to these abnormal forms, which in hierarchic develop¬ ment would lead to cancerous entities. The naturally existing levorotatory alkaline amino acids represent the constituents which, through their number and role in further organization, represent normal entities. Opposed to them, the dextrorotatory alkaline amino acids would represent abnormal entities. Their existence and their role has made the object of many discussions without, however, bringing sufficient light to this problem. The constant existence in the body of specific enzymes against these dextrorotatory amino acids in spite of the fact that they are not recognizable analytically, indicates a certain defense against them. The concept of their appearance as a resonance phenome¬ non would explain easily this occurrence. Dextrorotatory amino acids, al¬ though abnormal for the organism, exist in practically all individuals as a resonance form, but they are not able to develop—or develop in extremely reduced form—because of the enzymes which attack them. They are, how-

Google

UNIVERSITY OF MICHIGAN

552

/

RESEARCH

IN

P H Y S I O P A T H OL OO Y

ever, able to develop the lowest levels of cancerous entities as they are recognized to exist practically in ail normal individuals particularly after a certain age. There are these considerations which lead us to believe that it is the dextrorotatory resonance form of alkaline amino acids which repre¬ sent the abnormal entities at the lower levels. Chapter 4, Note 1. Physiological and Pathological Pain

Physiological Pain Physiological pain may be defined as a specific sensorial sensation in¬ duced in normal tissues when external stimuli are applied with sufficient intensity to endanger tissue integrity. Because pain may be induced by a wide variety of stimuli, it has not always been accepted as constituting a sen¬ sorial sensation. Considerable evidence exists, however, to indicate that physiological pain is a specific sensation, similar to the other sensorial sen¬ sations. One indication that pain is a proper sensorial sensation lies in the fact that its has its special nerve system. Blix (5) and Goldscheider (6) found that certain areas of the skin were sensitive to painful stimuli from a pinprick while others were not. Strughold (7) demonstrated that, in various areas of skin, pain points were concentrated in varying degree. Microscopic study of areas of skin showing high aggregations of spots of specific forms of sensibility has indi¬ cated that special sensory nerve and organ structures are apparently asso¬ ciated with different types of sensation. Thus, Krause’s corpuscles are considered as receptors for cold; Ruffini’s endings and Golgi-Mazzoni cor¬ puscles for heat; and Meissner’s corpuscles, Merkel’s discs and the basket endings around hair roots for touch. (8) Woolard (9) described unmyelin¬ ated, finely beaded, branched free endings as the specific nerve end organs believed to be responsible for the reception of pain impulses. Certain areas such as the cornea and the mucous membrane of the nose, which are gen¬ erally considered sensitive to pain alone, have been shown to have these free endings as the characteristic nerve endings at these sites. Weddell has found only this type of end structure in areas of skin sensitive solely to pain during nerve regeneration. That pain constitutes a specific form of sensation is further indicated by the evidence that its impulses are carried along definite nerve pathways to special centers in the thalamus. By temporary asphyxia, by cocainization, or by cooling, differential interference with conduction of the special sensa¬ tions of pain, touch, heat and cold along a nerve can be produced. The existence of individuals without the sensation of pain, but with sensations of touch, cold and heat, has confirmed this view of pain as a proper sen¬ sorial sensation. It is characteristic of the sensation of pain that it may be elicited by a wide variety of stimuli. Below the pain threshold, the incitation induces specific sensorial sensations according to the stimulus used. Above this threshold, the sensation felt is pain. When different noxious stimuli produce pain, the subject cannot distinguish the nature of the incitation. In effect.

Google

unqinai irom

UNIVERSITY OF MICHIGAN

NOTES

/

553

when it is below the threshold, the incitation informs about the nature of the stimulus; above the threshold, the individual is conscious of another fact: that the stimulus is of such intensity as to endanger the integrity of the tissues. Pain thus appears to be the sensorial sensation of a specific char¬ acter of stimuli—sufficient intensity to represent a danger for the tissues, and it is this which differentiates pain from the other sensorial sensations, and puts it into a special category. Pain is independent of the nature of the stimuli. By constituting a warning to the body, that its tissues are in jeop¬ ardy, physiological pain induces a general response involving brisk, rapid movements, a rise in pulse rate, and a sense of invigoration. (10) The fact that sensorial pain results from the intensity of the external incitations has prompted investigators to study this kind of pain largely in terms of the threshold of incitation. It must be emphasized that for each stimulus there exist two thresholds, one for intensity values required to produce specific sensations, and the second for intensity needed to produce pain. There is a considerable difference, for example, between the heat in¬ tensity necessary to produce a sensation of warmth and the amount that will produce a sensation of pain. Pathological Pain Pathological pain differs profoundly from physiological pain. It is a psychic response to impulses originating in tissues which are abnormal ei¬ ther because of damage produced by external stimuli or because of inflam¬ matory, circulatory, neoplastic, or other processes. When pain is present as a consequence of tissue damage or disease, it can no longer be considered as a warning of danger but constitutes a sign of injury. The general response to pathological pain is totally different from the response to physiological pain. Instead of the organism being prepared for fight or flight, its efforts are directed toward placing the painful injured area, or the entire body at rest; and, to protect the painful area from further injury, the pulse rate generally slows, the blood pressure falls and often there is sweating and nausea. (10) The local nature of the changes responsible for pathological pain has raised the problem of the several possible mechanisms of action which may intervene in inducing this pain. 1. Locally originated stimuli produced by damaged tissues themselves may act directly upon the pain end organs to induce pain impulses. Lewis has suggested that the pain associated with tissue damage is a result of the action of locally elaborated abnormal chemical substances. (10) This pos¬ sibility was first considered by von Frey (11) although actually the second pain described by him was due to different rates of pain impulse transmis¬ sion. Lewis (10) and his associates have studied pain in erythralgia which represents a typical form of pathological pain. (12, 13) They have shown that when skin has been injured and thus rendered hyperalgesic but not actually painful, simple arrest of circulation to this injured area may induce pain. A similar phenomenon is evident when a muscle is exercised vigor¬ ously while its circulation is arrested. If the constricting blood pressure cuff

Google

ERSITY OF MICHIGAN

554

/

RESEARCH

IN

P H Y S I O P A T H O L OO Y

is released, the pain that is experienced during the period of ischemia dis¬ appears, but if the cuff is reinflated, pain may recur without further exer¬ cise. In both instances, no new stimulus is required to arouse pain. It has been found that in erythralgia, neither vasodilatation nor change in skin temperature is the factor responsible for lowering the pain threshold. Ac¬ cording to Lewis, when the circulation to the affected area is severely re¬ duced, accumulated stable chemical substances elaborated by the damaged tissues may act directly as the pain stimulus. No definite evidence has been offered by these researchers, however, as to the chemical nature of the elaborated substances involved. 2. Local changes in damaged tissues may bring about a lowering of the nerve threshold for pain. Lewis has demonstrated the spread of the lowered threshold to nerves far beyond the site of the lesion itself. He studied the cutaneous hyperalgesia following tissue-damaging excitation of a tiny area of skin by a tapered forceps or faradic current. By producing damage in a previously anaesthetized area, he found that the local changes brought about by the damage did not produce hyperalgesia in the surround¬ ing skin until the effects of the local anaesthetic wore off. The localized nerve changes then created a wide zone of hyperalgesia for prolonged periods. Tower (14) has presented evidence to show that the receptor end structures for pain have an arborizing rather than a plexiform arrangement, thus making unnecessary the postulation of an autonomically unidentified “nocifensor” nerve system, as proposed by Lewis, (15) to account for the type of spread of the hyperalgesia. The extent and especially the distribu¬ tion of this area of hyperalgesia has clearly indicated that it is the result of a lowered threshold in the arborizing branches of the cutaneous nerve, a few branches of which were originally intensely stimulated. When a few fibers of a cutaneous nerve were directly stimulated, the same effect was observed. The findings suggested that a local tissue change lowers the threshold for pain for the nerve endings of the damaged area, and that this effect may spread through other branches of the cutaneous nerve involved as well as through larger nerve trunks so that the resultant area of hyper¬ algesia becomes very extensive. 3. Local changes may alter end organs ordinarily concerned with other forms of sensation in such a way that the impulses originated by them evoke the sensation of pain. Certain areas such as the appendix and the mucosa of the stomach apparently cannot, under normal circumstances, be incited to respond painfully to any form of stimulation. (16) However, in the presence of inflammation, the same stimuli may give rise to pain in these areas. The relationship between the end organs or nerves ordinarily concerned with the reception of other forms of sensation and those of pain has been considered by several authors. Weddell (17) has demonstrated that the various complex end organ structures are supplied with accessory fibers, unmyelinated and beaded, analogous to those considered to be pain receptors. Head (18) has shown in experiments on the glans penis that there may be a fusion of various sensations into a single concept and that one sensation may inhibit another. According to Feng, (19) the balance in

Google

ERSITY OF MICHIGAN

NOTES

/

555

excitability between touch and pain receptors may be upset peripherally by liberation of a chemical substance as the result of injury. Considerable evidence exists to indicate that pain is the most primitive form of sensation. It is possible that in the presence of pathological disturb¬ ances, through dedifferentiation complex systems for the reception and transmission of other modalities of sensation come to act as pain receptors. Whatever the exact mechanisms may be, the findings of different in¬ vestigators have led them to the conclusion that abnormal chemical sub¬ stances are released from pathologically affected tissues and that these chemical substances may play an important role in the production of pathological pain. Chapter 4, Note 2. Blood Titrimetric Alkalinity and Urinary pH The important role of the kidney in regulating the acid-base balance of the blood has been described (209) and a general relationship between daily acid excretion and plasma bicarbonate has been recognized. (210) However, a consistent relationship between blood acid-base variations and urine changes has not been clearly established. The determinations of blood pH and C02 combining power are the most commonly employed methods for following acid-base changes. How¬ ever, they indicate only certain distinctive factors intervening in acid-base balance. The pH is a measurement of the dissociated elements in the blood and is maintained within narrow limits by the buffer mechanisms, while the C02 combining power is a measurement of only one of the multiple factors in the buffer system, the bicarbonate group. (211) The inconsistent relationship between variations in urinary pH and blood values indicate that changes in urinary pH depend upon factors other than the blood’s dissociated substances and bicarbonate-carbonic acid buffer mechanism. The phosphates, proteins and hemoglobin are among the members of other important buffer systems that have a role in the control of the acid-base balance of the blood. (Figs. 203, 204) The titrimetric alkalinity of the blood represents a measurement of the totality (reserve supply) of the substances, both dissociated and nondissociated, that are involved in the maintenance of the acid-base balance of the blood. (212) We considered it interesting to examine the relation¬ ship between blood titrimetric alkalinity and urinary pH. Concomitant variations were compared. Human subjects and dogs without apparent kidney dysfunction were used. Blood was obtained by venipuncture with an accurately calibrated dry syringe. After the needle was introduced into the vein and before with¬ drawing blood, the tourniquet was released for several minutes to avoid changes due to stasis. Exactly 5 cc. of blood was introduced directly into a flask containing 30 cc. of a 0.00IN sodium hydroxide solution. The flask was immediately closed with a rubber stopper and the mixture agitated sufficiently to assure homogeneity. If determinations were not carried out at once, flasks were

Google

UNIVERSITY OF MICHIGAN

556

/

RESEARCH

IN

PH YSIOP ATHOLOGY

stored at 5°C and then brought to room temperature (20°C) before analy¬ sis. Fifty cc. of distilled water was used as a wash when flask contents were transferred to a beaker for titration. The total alkalinity was determined by electrometric titration to pH 7.0 against a .01N hydrochloric acid solurse

* 1

IS* 7*t ISO

tie He Wl

HO 7o

**

cc. HCl n/100

onrZ

a

5s 7o“After

r

Fig. 203. The comparison between the concomitant changes seen in various blood and urine analyses concerning the acid-base balance of the body. It shows that the variations of the titrimetric alkalinity of the total blood are the only values which constantly parallel those of the urinary pH. (Patient with breast cancer)

tion using a Beckman pH meter, Model G, and a mechanical stirrer. Blanks of 30 cc. of the sodium hydroxide solution were stored and treated in the same manner. Urine specimens from the human subjects were obtained through complete emptying of bladder contents by voluntary micturition. An in¬ dwelling catheter was used for dogs and some humans. Specimens were placed in containers closed with rubber stoppers and stored at 5°C. They

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

NOTES

/

557

were brought to room temperature before tests. The pH values were deter¬ mined electrometrically. Blood specimens were collected each hour for at least five consecutive hours. Urine samples were obtained every thirty minutes, as specimens ac-

t'.inulps

Fig. 204. In some cases the changes in several blood analyses parallel the changes of urinary pH. (Subject with metastatic melanoma)

cumulated in the bladder during the half hour preceding bleeding and again during the half hour following bleeding. The pH values of the urine speci¬ mens were plotted separately on graphs as A and B curves. Comparison was then made between the two urine curves and the curve representing the values of the blood titrimetric alkalinity, using time as abscissa. In another group of experiments using dogs, the bladder contents were drained at in¬ tervals of from five to ten minutes and blood specimens were obtained every thirty minutes.

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

558

/

RESEARCH

IN

P H Y S IOP A THO L OOY

Several preliminary tests were carried out to determine the degree of accuracy of the methods used. By employing a 0.00IN NaOH solution, a probable error of no more than 0.1 cc. was found. Comparisons between titrimetric alkalinity of hourly blood specimens and half-hourly urine specimens were made in thirty human and seven

Fio. 205. The comparison between the concomitant values of urinary pH and of the titrimetric alkalinity of the blood shows that this relationship concerns more the occurring changes and less the absolute values of the findings. Urine samples with the same pH, in different subjects, are seen to correspond to blood samples with dif¬ ferent titrimetric alkalinity.

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

NOTES

/

559

canine subjects. In all cases, the curves of blood titrimetric alkalinity values showed a consistent parallelism to the pH curves of urine specimens that accumulated in the bladder during the thirty minutes preceding the bleeding and were collected at the time of venipuncture. (Fig. 206) The curves repre¬ senting the pH values of urine specimens accumulated in the bladder dur-

Fio. 206. Comparison of the hourly blood titratable alkalinity (in terms of cc. of .OIN HC1) and half hourly pH curves in a human subject. Urine curves A and B represent the before and after bleeding specimens. The parallelism between the titratable alkalinity of blood and the urine curve A is clearly shown. Curve B shows no correlation.

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

560

/

RESEARCH

IN

P H Y S IOP A TH O L OGY

ing the thirty minutes after each bleeding (B curves) did not show the same consistent correlation to the blood titrimetric alkalinity. (Fig. 207) In several tests, collections of half-hourly urine specimens were made fifteen minutes before and fifteen minutes after each bleeding. The same parallelism was found between the pH of urine accumulated in the bladder during the period from fifteen minutes before to fifteen minutes after bleed¬ ing, and the titrimetric alkalinity of blood specimens drawn in the middle

Blood /ru m

cc urn fT^

r—

/

i

2

- i

i

3

4

"T———>--

5

6

Hour Fio. 207. Comparison of the curves representing hourly blood titratable alkalinity (in terms of cc. of .OIN HC1) and urine pH in a human subject. Urine pH curve “Before" shows values of specimens accumulated in bladder during the half hour immediately preceding and collected at the time of bleeding, while urine pH curve "After" is for specimens collected one half hour after bleeding. There is a definite parallelism only between the curves of the titratable alkalinity of blood and the urine pH curve A.

of the urine collection period. The pH curves of urine specimens accumu¬ lated during the period from fifteen to forty-five minutes after each bleed¬ ing showed no consistent correlation. When urine and blood specimens were obtained at shorter intervals, the same tendency of urine pH changes to precede the changes in blood titrimetric alkalinity was observed. In Figure 208 a rapid rise in urine pH is seen to begin within twenty minutes of the time of administration of sodium bicarbonate. The blood titrimetric alkalinity does not show an elevation for at least forty-five minutes.

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

NOTES

/

561

These studies have shown that urinary pH variations correspond closely to changes in the values of an important factor reflecting acid-base balance changes of the blood, the titrimetric alkalinity. As a result, it has been possible to employ variations in urinary pH as indications of qualitative changes in acid-base balance of the blood for other studies.

Minvtti Fio. 208. The effect of the administration of 5 grams of sodium bicarbonate upon the blood lilratable alkalinity and urine pH curves in dog. The elevation in urine pH is seen to precede by twenty-five minutes that of the titratable alkalinity of the blood.

Chapter 4, Note 3. Acid Pattern of Pain and Lactic Acid We have investigated the relationship between pain of acid pattern and the appearance of lactic acid resulting from abnormal metabolism of carbohydrates. For this purpose we used the technique of Friedemann, Cotonio and Shaffer. In several patients it appeared possible to establish this relationship by measuring the lactic acid content of efferent blood from tumors during intensive pain of acid pattern. In a young man with a huge sarcoma of the knee, for whom the acid pattern of the pain had been established through its relationship to the changes in the urinary pH, such analyses could be carried out in the blood obtained from the big easily accessible efferent veins. At the moments of very severe pain, the amount of lactic acid had markedly increased. Values as high as 128 mg./100 cc. blood were found during these painful periods, contrasting with values around 30 mg./100 cc. blood in the period of calm.

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

562

/

RESEARCH

IN

P HYS I O P ATH OLOGY

Chapter 4, Note 4. Itching Although we were especially concerned with pathological itching, we also became interested in physiological itching, especially in its relationship to sensorial sensations in general. Physiological itching can be regarded as a distinct sensation, not just a gradation of another sensation. Itching seems to have its own end organs. The propensity of certain regions of the body—such as the nasal mucous membranes, the skin near the nostrils, and the perioral and perianal skin—to itch in response to external stimuli can be correlated with the presence of such end organs. The proteopathic character of itching would also prompt us to consider less myelinized or even nonmyelinized nerves as its conductors. By analogy with pain, the existence of proper central centers could be conceived. The most important characteristic of itching is that it can be induced by stimuli which, at other intensities, result in a different sensation such as touch, for instance. Although less manifest, other stimuli, such as heat and cold, also can induce itching. We have seen that stimuli which usually in¬ duce other sensations can produce physiological pain if they have an in¬ tensity above a threshold level. It is the intensity of the stimulus which determines whether it causes pain or a sensation of touch, heat or cold. Since pain appears if the stimulus is above the threshold level, it serves as a warning of a damaging incitation. In studying itching under a similar aspect, it can be seen that it, too, is induced by nonspecific stimuli. But, for itching, the intensity of the stimuli is low. Everybody knows that an essential condition for the induc¬ tion of itching is that the incitation be slight. This is easily seen for the skin, and especially the nasal mucous membrane, where a stronger stimulation will not induce itching but a touch sensation. Just as the intensity of a stimulus determines whether pain or touch is produced, so the intensity also determines whether itching or touch is felt. While the sensorial sensa¬ tion of touch is induced by stimuli with intensities below those required for pain, itching is induced if intensities are below those required for touch. The relationship of intensity of stimulus to itching, sensorial sensation of touch, and pain is shown in Figure 208 bis. This correlation explains why itching is present sometimes for a brief period when skin or mucous membrane sensorial sensation or even pain is induced. Immediately after an injury, for example, itching may be felt for a short time only to dis¬ appear just prior to the development of pain. The low intensity of the stimulus required explains a striking characteristic of itching: its disappear¬ ance when a stronger stimulus is applied. Thus scratching, which adds more intensive stimulation, makes itching disappear. The more violent the scratching, even to the point of inducing pain, the more effective it can be in eliminating itching. The general reaction toward itching also appears related to the char¬ acter of its induction. The individual responds to pain by fleeing or fighting in order to escape the intensive noxious incitation. As the incitation that produces itching is minimal by definition—the presence on the skin of a

Google

UNIVERSI

1ICHIGAN

NOTES

/

563

minor irritant such as a fly or mosquito, for instance—scratching is suffi¬ cient to eliminate it. With a fly on his skin, the individual need not flee or fight, but only scratch. With the concept that itching can result from exactly the same type of stimuli as pain and touch, we integrate it in the group of sensorial sensations. We can then establish a separate sensorial subgroup for itching and pain. While other sensorial sensations inform us of the nature of the excitation—heat, cold, sound, taste, etc.—itching and pain inform us only about the intensity of the stimulus, not its nature. Pathological itching, like pathological pain, is related to the existence of abnormalities. In addition to the differences in stimulus intensity required to induce itching and pain, their different nervous formations help explain their clinical separation. No patient we have studied has ever indicated any confusion as to whether his discomfort was due to severe itching or pain. The two sensations are seldom concomitant; usually they succeed one another. The fact that proteopathic pain and itching both seem to be conducted through unmyelinized nerves indicates why they can appear under similar conditions, as in nerve regeneration. This seems to have led to confusion between itching and pain. However, itching and pain ob¬ served during nerve regeneration can be clearly differentiated by the pa¬ tient. The fact that the itching sensation is produced by stimuli of low intensity also explains why itching is so often present on skin or mucous membranes without appreciable pathology. Minimal changes appear suffi¬ cient to induce the sensation.

Fio. 208 bis. Similar to pain, itching represents a special kind of sensation, with the aim to inform about the intensity of the excitation. If this is very slight, it induces itching. If above the threshold, at which the incitation acquires a noxious character, it induces pain.

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

564

/

RESEARCH

IN

PHYSIOPATHOLOGY

uays Fio. 209. The nasal pH measured with a glass electrode introduced deep in the nose shows the same dualism as the other analyses. With 6.5 as the average value, the curves of the nasal pH has more rapid and broader variations than other analyses. Curve of daily analyses shows values above the average line in a case of generalized melanoma.

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

NOTES

/

565

Chapter 4, Note 5. Nasal pH Nasal pH was measured using a portable Beckman pH meter and a glass electrode small enough to penetrate deep into the nose. In a research made with N. Buchanan it was found that valid data could be obtained only if the electrode touched the turbinate, otherwise marked differences in values were noted.

Fio. 211. The relationship between daily changes of the nasal and urinary pH shows opposite variations.

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

566

/

RESEARCH

IN

PHYSIOPATHOLOGY

In a simplified method, cotton applicators were soaked in Guillaumin indicator solution with methyl red and bromothymol blue and left to dry. They were easily introduced to sufficient depth in the nose and left in place for at least two minutes. Color of the wet spots was checked with a colori¬ metric scale. Data obtained with glass electrode and colormetric applicator were found to coincide closely. Two offbalances could be seen, one with the pH elevated sometimes even above 8. Figures 209 and 210 show curves of the offbalance in two patients. It is interesting to note that the changes in the nasal pH values parallel these seen at the level of lesions and are opposite to those con¬ comitantly occurring in the urinary pH (Fig. 211) which parallel those of the titrimetric alkalinity of the blood. Chapter 4, Note 6. Wheal Resorption Interesting information could be obtained by analyzing the absorption of fluid injected intradermically in various subjects, and correlating the results with the existence of metabolic offbalances. We used the tech¬ nique proposed by McClure and Aldrich, in which they measured the time needed for the disappearance of a wheal, resulting from an intracutaneous injection of a saline solution. A relatively extensive study of absorption was made in more than 500 subjects—both normal and ab¬ normal. We present here a few of the conclusions from this study. The average time necessary for resolution of the wheal obtained by the injection of .2 cc. of 7% NaCl solution, in normal subjects, was 23 min¬ utes; the range was from 15 to 30 minutes. When deviations from these values were observed, they were consistent, in the sense that tests repeated at short intervals in the same general area in the same subject gave values in the same abnormal range. Abnormal values occurred in two directions. Resorption time was shortened in some cases and values as low as 1 to 2 minutes were noted. In the opppsite direction, values as high as 90 min¬ utes were observed. These deviations from normal time could be related to local and general conditions. The presence of local or regional edema shortens the resorption time so much, that in some cases with massive edema, no wheal could even be realized. Shortening of time was found to be true for an edema, regardless of cause—inflammation, impaired local circulation as in phlebitis, impaired general circulation as in cardiacs or in renal failure. Lengthening of resorption time in cases of phlebitis provides valuable information on the evolution of the condition. The return of resorption time to normal values seems to indicate sufficient improvement to permit mobilization of the patient. In subjects in whom no local factor could be considered to be responsi¬ ble for changes in the resorption time of the wheal, we could see that abnormal variations had a direct relationship with the general offbalance present. In some subjects with a manifest offbalance of type D, wheal resorption time was shortened. Values as low as 4 to 5 minutes were ob¬ tained. Analysis of a number of cases indicated that this shortening of

Google

UNIVERSITY OF MICHIGAN

NOTES

/

567

resorption time meant a bad prognosis. A few patients with only values of 2 to 4 minutes died within a few days although other symptoms gave no indication of a fatal outcome within a snort time. Extended resorption time has been found in subjects with an offbalance of type A. Values as high as 60 to 90 minutes were found in sub¬ jects in whom all other analyses indicated this offbalance. It is also interesting to note the existence of slow resorption time for aged subjects. In a group of 80 patients ranging from 70 to 90 years of age, an average resorption time of 90 minutes was found. (Fig. 68) Chapter 4, Note 7. Eosinophiles The role of the blood as the secondary part of the entity organism has explained many of the peculiarities of its cells. Aside from the phagocytary functions that can be considered as a particular form of capturation, the leucocytes have to be recognized as acting as holocrine monocellular forma¬ tions whose specific constituents are liberated by cellular lysis. We have seen that in the case of the neutrophilic granulocytes, the hydrolytic en¬ zymes so liberated, strongly resemble the external secretion of the pancreas. Under this aspect, we have investigated the blood eosinophiles with a role similar to the Paneth cells of the duodenum. The physiology of these leucocytes has to be sought in the acidophilic character of their granules. Morphological analysis of the eosinophile granule shows that it is formed by a content and a membrane, the last clearly seen in preparations in which the granules have lost their content. Like many other membranes, that of the eosinophile granule can be easily identified as being made partially at least by lipids being stained with dyes dissolving in lipids, such as black Sudan or Scharlach. However, it is the content of the granule with its ability to combine with acid dyes that indi¬ cates its specific characters. Under certain circumstances, when the blood is maintained in vitro between the slide and cover object for a certain time, the membrane and granule content are seen to separate. Before this occur¬ rence, a lysis of the eosinophile leucocyte itself takes place. This is mani¬ fested through the breakdown of the cellular membrane with the lysis of the nucleus. It is in a second step that the eosinophile granule loses its con¬ tent. Following it, besides the empty granules and lysed eosinophiles, char¬ acteristic Charcot-Leyden crystals appear. The correlation between these crystals and eosinophiles has been recognized and is generally accepted as occurring in vivo and in vitro. Ayer (215) has shortened the process of lysis of the eosinophiles in vitro by treating the blood preparations with a detergent, aerosol. By re¬ peating Ayer’s experiments, the relationship between the appearance of the Charcot-Leyden crystals and the more complex process of lysis of the eosinophiles has become apparent. It could be seen that the crystals would appear at the site where the nuclei of the eosinophiles disappeared through lysis, and where careful observation of the granules reveals the loss of their eosinophilic content. The presence of empty granule membranes

Google

UNIVERSITY OF MICHIGAN

568

/

RESEARCH

IN

P H Y S I O P A T H OL OOY

stained by the fatty dyes, in addition to the lysed nuclei, would indicate the conditions under which Charcot-Leyden crystals appear. The eosinophilic content of the granule and products induced by the nuclear lysis represent the two factors that together result in these crystals. Concerning the relationship between Charcot-Leyden crystals and eosinophiles, it is interesting to note the difference that exists between eosino¬ philic granules in various animals. Besides the morphological aspect which can be very different, apparently no Charcot-Leyden crystals are obtained from species other than humans and certain simians. This indicates that when the biological role of the eosinophiles is considered, we have to seek another common factor in addition to the morphological and chemical ones. It would seem that it is in their basic reactivity, i.e. in their capacity to bind substances of acid character, that the common character of all eosinophile granules has to be sought. This is also true for the duodenal cells. Following this view, we initially tended to accord more importance to an antacid property than to any other, seemingly agreeing with other data obtained from this study. Among the substances found to be the principal constituents of these eosinophile granules, the alkaline amino acids, of which arginine is the the principal one, assume a very important role. Ac¬ cording to the hypothesis we advance, these alkaline amino acids would represent the active factor of these granules and would be liberated by the eosinophiles when they disintegrate. The eosinophiles would intervene in physiology for the specific purpose of furnishing certain alkaline com¬ pounds in whose constitution the alkaline amino acids enter. The solubility of the granule content, when liberated, and the Charcot-Leyden crystals indicate, according to this view, that the main character of the eosinophile granule is its capacity to furnish alkaline compounds. Under special cir¬ cumstances, they are able to act against substances with acid properties that result from the lysis of the nuclei, and together to form the CharcotLeyden crystals. The relationship of the disintegration of the eosinophile to the surface tension lowering agents is also interesting for the further liberation of the content of these granules. Just as for other granulocytes and lymphocytes, lysis is the characteristic fate of these cells and would constitute their most important character. As seen above, it can be related to the role of blood in the organization, i.e. as the secondary part of the organism level. As for the other leucocytes, an important factor in the holocrinic role of the eosinophiles has been seen in the necessity of a maturation of these granules for their active intervention. When lysis was induced, it was seen to affect only the cells that had reached a certain degree of maturity, not only for the cells themselves but also for the granules. Young cells, recog¬ nized by more intense basophily of the cytoplasm, by lack of, or reduced lobulation of the nucleus, and especially by a neutrophilic or even baso¬ philic character of the granules, do not break down. As in the circulating blood, immature elements are seen, the delay observed in inducing eosinopenia by various agents can be interpreted as corresponding to the time needed for the circulating eosinophiles to reach maturity, as an essen-

Google

TY OF

NOTES

/

569

tial condition for their lysis. This situation was apparent in a particular case, that of eosinopenia induced through administration of the adrenal corticoids. Although this appears to have a direct effect upon the eosinophiles, a definite time, often even 24 hours, is seen essential in order to achieve the disappearance of the eosinophiles from the circulating blood. This delay has been related to the presence of eosinophiles, allegedly “re¬ sistant” to the corticoids. In fact, in studying the eosinophiles which persist after the administration of these hormones, we could see that they repre¬ sent only immature elements, probably prematurely liberated in larger amounts from the bone marrow. The cells from which some will persist even for 24 hours after administration of corticoneoglucogenic hormones, do not show lysis in vitro nor the appearance of Charcot-Leyden crystals, and they present the tinctorial characters of immaturity for the cytoplasm and especially for the granules. Granule maturation, which corresponds to the acidophilic character, seems to be the essential condition for the lytic intervention of these cells. In the physiological role of eosinophiles, an important aspect of matura¬ tion was seen in the relationship between the richness of these elements in the circulating blood and the processes in which a manifest local eosinophilia is induced, as through injection of parasite larvae or vegetal oils. A direct relationship between local and sanguine eosinophilia was appar¬ ent, the value of the former being the function of the latter. The ability of bone marrow to rapidly compensate the transitory eosinopenia following the passage of these cells into the tissues, has further directly connected the local richness in eosinophiles to the bone marrow’s capacity to send new cells into the circulation. In all these changes, the prevailing factor has apparently been the degree of maturity of the eosinophile granulae, which seems to require a certain time to reach the desired degree which is the principal condition also for their physiological intervention. Correlation between the biological intervention of the eosinophiles and the acidophilic character of the granules and their richness in alkaline amino acids has been confirmed in a study of the basophiles of the blood cells with granules having an opposite character. These granules have an acid content, as seen by their tinctorial affinity for alkaline dyes. They were also observed to contain heparine, a polysulfonated mucoid of frank acid character. The biological antagonism between heparine and alkaline proteins is well known. Protamines, the correspondent of histones for fish, are used to correct the excesses of heparin in the body, especially as thera¬ peutic measures. Therefore, the antagonism between eosinophilic and baso¬ philic granulocytes goes beyond their tinctorial characters. Through the alkaline reactivity of eosinophiles as related to the funda¬ mental separation of intervening constituents according to their positive or negative character, the antacid eosinophiles could be considered to be in the former group, while the basophiles, rich in lytic heparin, are in the latter. We shall more fully discuss below the nature of the intervention of the eosinophiles after studying the role of a special group of constituents. For

Google

|

ERSITY OF

EHIGAh

570

/

RESEARCH

IN

PHYSIOPATHOLOGY

the present, it seems that under abnormal circumstances, exaggeration in the amount of eosinophiles would indicate an existing predominance of conditions that correspond to agents of positive character, i.e., with heterotropic tendency. The more precise antacid character of these cells further indicates the place that has to be reserved for the eosinophiles in the group of heterotropic agents. Under this aspect, the eosinophile would be seen as an agent of anti-acid character in the blood and tissues, conceived to act as a holocrinic cellular gland, i.e., through the lysis of the corresponding cell. Therefore, the richness of the blood and tissues in eosinophiles would indicate a predominance of heterotropic tendency, while paucity in eosino¬ philes or their absence would indicate a homotropic trend.

Oays Fig. 212. Curve of blood eosinophiles in a case of breast adenocarcinoma with multiple metastases, showing values persistently below the average line of 100.

In order to understand this aspect of the eosinophiles, we tried to fol¬ low the changes in their amount in the blood in relation to normal and abnormal physiology. Study of the changes in the number of eosinophiles in the circulating blood under physiological conditions has indicated the existence of the same 24-hour oscillations as seen for many other con¬ stituents of the blood. A relationship is apparent between the periods corre¬ sponding to higher or lower quantities of circulating eosinophiles and the degree of activity of the individual. This appears to be opposite in humans who show diurnal activity, and mice and rats that show nocturnal activity. By experimentally changing the hours of light and dark for mice and rats, and through it the time of rest and of activity, the rhythm of change was reversed. Following the concept of the intervention of eosinophiles in biological balance, we further investigated this aspect of the problem in relation to the dualism in abnormal conditions. Just as for other tests, we obtained an

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

NOTES

/

571

average value in a large series of normal human subjects. Utilizing the Dungar technique for a direct count of eosinophiles, the value of 100 cells/1 cmm. was found to be the average value. An impressive direct correlation could be found between the amount of circulating eosinophiles and the two patterns of abnormality. In one group, that corresponding to type A, the number of eosinophiles appeared not only high but with their values fixed above the average value. High values were observed to persist for long periods of time. Figure 213 shows such a case. For the opposite pattern, corresponding to the fundamental type D, these values appeared to be below 100 and very often 0, persisting for a long period of time. (Fig. 212) In these dual patterns, the degree of abnormality could be related to the deviation in the number of these elements from the average value of 100 elements/1 cmm.

Days Fio. 213. Curve of the blood eosinophiles in a case of generalized melanoma show¬ ing values persistently above the average line of 100.

The relative facility with which the number of eosinophiles in the blood of an individual can be determined, has made it an important research tool for information regarding the balance between the two fundamental bio¬ logical tendencies. Chapter 4, Note 8. Total Blood Potassium For a large-scale investigation—requiring as many as one hundred de¬ terminations a day—the technique of separating red cells from plasma appeared to be impractical. In view of the relatively minute amounts of potassium in plasma as compared to cells, we could utilize total blood instead of the cells. It was also found that by diluting the blood 1/10, the values obtained were in the same range as for serum potassium, a fact which permitted the use of the flame photometer without any change in the

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

572

/

RESEARCH

IN

P H Y S I O P A TH O L OG Y

Fig. 214. Relationship between serum K + and total blood K+ permits to recog¬ nize the nature of the changes concerning the intervention of this element. In a case of periarteritis nodosa, the high values of serum potassium and low values of the total blood potassium indicate an offbalance type D.

Fig. 215. Low values of serum potassium and high values of total blood potassium indicate an offbalance type A in a case of cancer of the gallbladder.

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

NOTES

/

573

set-up of the apparatus. The blood was diluted with a 1 % acetic acid solu¬ tion in the pipette used for counting white cells. The pipette was shaken as for the count of cells, and the necessary amount taken from the diluted content. The potassium amount was determined and the result multiplied by 10. While the average value for the total blood was found to be around 38 mEq., values as low as 20 or as high as 60 were seen. (Figs. 214, 215,

and 216)

Fig. 216. Low values of potassium in senim and in total blood indicate a quantitative deficiency, in a subject with a liver adenocarcinoma. The administration of 40m Eq KC1 daily, for 9 days brought the two curves to normal.

Chapter 4, Note 9. Sulfhydryl Determination The catalytic effect of sulfhydryl groups on the oxidation of sodium azide by iodine was first described by F. Raschig (214), and F. Feigl (217) utilized it to develop the most sensitive qualitative test for the presence of sulfhydryl containing compounds. The reaction, initiated by mercaptans, sulfides, thiosulfates and thiocyanates, takes place as follows 2 NaN3 + I2 = 2 Nal + 3 N2 While this equation implies that the sulfhydryl compounds do not take part in the reaction, this is not entirely correct, because simultaneously, the sulfhydryl groups are oxidized by the free iodine. Accordingly, the reaction is carried out in a Warburg apparatus, where 1 ml. of 0.2 M sodium azide

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

After

Before

l v—vs m

Cod liver oil

Octanol

. ti

- ♦

Bef ore

Before Unsaponiftable fraction of

Epichlorohydrin

Before Before

After

After

After Sodlua Thiosulfate

Before Fig. 216B. Electrocardiograms, in first lead in rabbits injected intraperitoneally with sublcthal doses of different agents. In the group with lipoids with positive polar groups besides other changes, a flattening of the wave T is induced, which contrasts with a more elevated T for the group of lipoids with negative character.

and 1 ml. of 0.1 M iodine-potassium iodide solutions are mixed, while the sulfhydryl containing solution is kept in the sidearm, and then added to the reagents after temperature equilibrium is reached. Upon complete mixing, there is rapid nitrogen evolution, which, however, ceases within 13 min¬ utes. The amount of nitrogen evolved is found to be linearly proportional to the content of the sulfhydryl groups, and on the average, 1 ml. of urine, 0.05 ml. of blood or 1 ml. of a 3 x 10~4 M sulfhydryl containing solution are amply sufficient for an assay. The method is thus well applicable to the determination of sulfhydryl levels, provided the method is standardized with the appropriate compound to be tested, as the catalytic effect of all mercaptans is not the same. (218)

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

NOTES

/

575

Chapter 4, Note 10. Calcium in Urine 1 cc. of the urine was diluted in a test tube with 8 cc. of distilled water and the optical density of the mixture was determined. To the mixture, 1 cc. of a 1% solution of potassium oxalate and 3% of oxalic acid was added. After standing for 5 minutes, the tube was shaken and the optical density again was read. The difference, multiplied by 10, was divided by the two figures of the specific gravity of the sample. The value obtained was called the calcium index. Chapter 4, Note 11. Urinary Surface Tension (ST) The role of changes in the surface tension of various body fluids in normal and abnormal physiology has become of increasing interest. Some authors have gone so far as to consider the surface tension forces present at the interfaces separating entities, to be the most important factors in the boundary formations which serve to individualize these entities. Considering multiple aspects of the problem, it appeared interesting to attempt, as a first step, to obtain information about the surface tension of different body fluids. It was as part of this program that urinary surface tension was investigated with the intention of utilizing the data to gain in¬ sight into changes related to the dualistic offbalances. Before we could pro¬ ceed, it was necessary to resolve several problems, including the technical difficulties in measuring surface tension that result from the special consti¬ tution of the urine. Technical Problems Successive measurements of surface tension, when made on fluids formed by a single substance, consistently furnish the same value. But for fluids composed of two or more constituents, values vary from one mo¬ ment to the next. This is explained by the fact that molecules of constituent substances have a tendency to migrate in the fluid, some accumulating at the surface, others concentrating in the bulk. (Gibbs dictum) The surface tension of different complex fluids has been found to vary according to the nature and amount of tensio-active substances present. And, study of the variations has furnished information about the nature of these sub¬ stances. In a fluid such as urine, containing many different substances, the prob¬ lem of variations in surface tension is a major one. ST measurements, made without considering these variations, would be subject to serious errors. Examination of different samples of urine has shown great differ¬ ences between values obtained at different times. Using Lecomte du Noiiy’s tensiometer (215) it could be seen that, for the same urine sample, values vary according to the length of time the sample is left to stand. Values progressively decrease as standing time increases. Similar changes are seen when the pendant drop method is used. (216) Because of the fact that a certain time is needed for changes to take

Google

UNIVERSITY OF MICHIGAN

576

/

RESEARCH

IN

P H Y S I O P A T H OL O O Y

place, the relationship between change and time was investigated. The study of various urine samples has emphasized the inequality which exists between them not only in the intensity of changes but also in the time necessary for the changes to take place. This fact has rendered useless the measurement of the surface tension of different samples if all are made at some given moment. Except for measurements made at frequent intervals, use of du Noiiy’s tensiometer has appeared to be inadequate for urine. Traube’s stalagmometer also is unable to furnish values that take these changes into account. Theoretically, it would appear possible to obtain measurements that would correspond to the surface tension for each drop at a desired mo¬ ment by changing the rate of flow of the urine through the apparatus. But the differences between urines, related to changes in distribution of com¬ ponents, have made this inadequate. With the pendant drop method, progressive changes which occur in the shape of the drop would appear to indicate the changes in surface ten¬ sion. (216) Technically, it would appear necessary to obtain data as fre¬ quently as possible in order to follow changes which occur at various times. By using serial pictures, the changes, the moment of their occurrence, and their intensity can be studied accurately. Unfortunately, the complexity of the method, with the need for frequent pictures and involved calculations, prohibits its use for routine measurements and, consequently, for any broad clinical and experimental research. It was under these circumstances that we returned to the capillary method which we considered capable of furnishing the desired data. Classi¬ cally, the height of the ascending column in a calibrated capillary is used to calculate the surface tension. Height alone, however, is unsatisfactory, since it does not reveal the changes that take place. It was by studying the descent of the column in a capillary that we were able to obtain the data which we were seeking. We could show that the column does not descend with uniform velocity. It stops or slows down perceptively several times before it comes to rest at a fixed value. We could recognize that, for most urine samples, there is a first stop usually of several seconds duration. In some urines, this first stop is replaced by a marked slowdown in velocity of descent. The stop or slowdown is followed by renewed but slower descent and a second stop somewhat longer than the first. After another descent, often lasting more than 20 minutes, a new stop occurs. The time of descent, the duration of the stops, and especially the heights of the column at which the stops occur, while reproducible for the same urine, vary widely with different samples. They would thus indicate different repartitions and the times when they occur. This technique of using the capillary consequently appears to be adequate for the study of the surface tension of complex solutions and particularly for the study of urine. Each of the heights at which the descending column stops would indi¬ cate the surface tension for a particular stage in the repartition of the con¬ stituents. In studying this problem further, it appeared advisable to try to

Google

ERSITY OF

HIGAN

NOTES

/

577

have the capillary so calibrated as to permit a direct reading of surface tension values at these stops. The study of the relationship between the surface tension of a fluid and the height of the column has indicated the nature of intervening factors, their values, and under what conditions a direct reading is possible. The fluid column remains stationary in a capillary tube when the sur¬ face forces which bind the column of fluid to the wall of the capillary are equal to the weight of the fluid column. With a representing the surface tension; r, the radius of the capillary tube; h, the height of the column; A, the specific gravity of the fluid; and g, the acceleration of gravity, we have 2 w r a = * f* hg A. It can be seen that the specific gravity is the only factor related to the sample, other than the surface tension, which intervenes in determining the height of the fluid column. According to this formula, the relationship between the surface tension and the specific gravity of the specimen is: a = —The same height of the column is obtained if the relationship between surface tension a and a of two different liquids with the specific gravities A and A' fulfills the con¬ o'A' dition: a A

#

If measurements with a capillary tube having a bore radius of 0.5 mm. are made in New York City, where the acceleration of gravity is 981 upon water which at 18°C has a surface tension 73 dynes/cm., the height of the fluid column is found to be 6.0 cm. and the relationship between o and A, expressed in the cgs. system is o = 73 A. A capillary tube thus can be calibrated to permit the direct reading of the surface tension in dynes/cm. for any liquid having the same specific gravity. For fluids of different specific gravity, the same capillary tube can be used if a correction of 0.073 dynes/cm., is made for each 0.001 incre¬ ment of the specific gravity. Urinary specific gravity values encountered clinically range between 1.001 and 1.035, with an average value around 1.015. Tubes calibrated to measure urine specimens with specific gravity values at either extreme can yield errors in the surface tension of as much as 2 dynes/cm. In order to minimize the degree of error for routine laboratory use, the capillary tube has been calibrated to correspond to a fluid with a specific gravity of 1.015. The maximum error of the surface tension values for the extremes of specific gravity clinically observed will be reduced to approximately ± 1 dyne/cm. in this way. Furthermore, the fact that sodium chloride concen¬ tration is one of the important factors inducing different values for urinary specific gravity reduces the influence exercised by specific gravity upon the height of the column. Sodium chloride represents a negative surface active substance. It will raise the surface tension values as its concentration in¬ creases because of its tendency to migrate from the surface toward the bulk of the fluid. This will partially decrease the influence exerted by the specific gravity of the urine. Since the surface tension values of human urine speci-

Google

Original from UNIVERSITY OF MICHIGAN

578

/

RESEARCH

IN

PHYSIOPATHOLOGY

mens measured by this method have been found to vary between 73 and 50 dynes/cm., the error for extreme values of specific gravity is less than 5% and is not clinically significant. If more precise values are desired, the necessary correction can be made by adding or subtracting 0.073 dynes/cm. for every .001 difference in the sample above or below the specific gravity for which the tube is calibrated (i.e. 1.015). The temperature of the urine to be tested is another factor which inter¬ venes. Although the fluid rapidly attains the same temperature as the capil¬ lary walls, it is advisable to perform measurements when the temperature of the fluid is around 18°C, since the surface tension of a liquid decreases as its temperature increases. For clinical use, corrections for differences in temperature are not considered necessary. Design and Calibration of the Urotensiometer

In order to obtain direct readings of the urinary surface tension values with a maximum error of ± 1 dyne/cm., the previously discussed factors were taken into consideration in designing and calibrating the urotensiom¬ eter which we conceived. (Fig. 217) The glass capillary tube has a bore

14 cm

Fio. 217. Urotensiometer—calibrated to indicate by direct the surface tension of fluids having a specific gravity of 1.015.

readings in dyne/cm

diameter of 0.5 mm. and is approximately 14 cm. in length. It is calibrated to indicate the surface tension of a fluid with a specific gravity of 1.015 directly in terms of dynes/cm. in the following manner: a continuous column of distilled water at 18°C is drawn up to about three-fourths of the height of the tube and allowed to descend with the tube maintained verti¬ cally. The point at which the top of the column stops is marked. It repre¬ sents a surface tension of 73 dynes/cm. for water having a specific gravity of 1.000. In order to make the necessary correction for a fluid having a specific gravity of 1.015, the distance between this point and the tip of the tube is divided into 74 (instead of 73) equal parts. The tube is calibrated down to 50 dynes/cm. since lower values have not been encountered. In the tubes manufactured by Clay Adams, New York, the markings are per¬ manent. The split line feature of the scale permits easy visualization of the meniscus. The encircling lines help in maintaining the tube in the vertical position. The Measurement of Urinary Surface Tension with the Urotensiometer

To determine surface tension by means of the Urotensiometer, the tapered end of the tube is introduced into the bulk of the urine specimen.

Digitized by

Goo

UNIVERSITY OF MICHIGAN

NOTES

/

579

The fluid is drawn slightly above the highest mark by mouth suction and evacuated several times by positive pressure. The tube is again filled to the same point, care being taken this time that no air bubbles interrupt the continuity of the fluid column. The tube is removed from between the lips, and the tip of the capillary is then gradually raised toward the surface of the fluid. When the top of the column descends to the top line (T) of the scale, the tip of the tube is removed from the fluid and maintained in a vertical position at eye level. The descent of the top of the column can best be observed by viewing the meniscus between the ends of the split line calibration markings. The top of the column descends within one or two seconds to an initial point (Pi) where it comes to a temporary halt or its rate of descent suddenly slows perceptibly. The column again slowly de¬ scends, coming to rest after several minutes at a second point (P2). After some time, the descent may again be resumed at a much slower rate until a third and final stopping point (P3) is reached after more than fifteen minutes. For routine measurements, the first reading (Pi) is considered as the surface tension value of the urine. This corresponds roughly to the surface tension value of the specimen before any important secondary re¬ distribution of molecules has taken place. The capillary tube should be thoroughly cleaned with distilled water after use. It is well to check the tube before each series of measurements, using distilled water at room temperature. If the check readings are above 74 or below 73 on the scale, the tube must be carefully flushed through with distilled water by means of a suction pump. Occasionally, water alone may not be sufficient and it will be necessary to clean the tube with sulfuricochromic cleaning solution, followed by thorough flushing with water, in order to obtain correct check readings. When the tube is not in use, it is best left standing in a glass beaker containing distilled water. Surface Tension in Clinical and Experimental Research

The Urotensiometer for the first time makes possible determinations of the surface tension of urine and other physiological solutions as a routine laboratory procedure. The highest surface tension value for urine en¬ countered clinically is 73 dynes/cm., and this is correlated with a minimal quantity of surface-active substances. The lower the surface tension of the urine in dynes/cm., the greater the amount of tensio-active agents present in the specimen. A surface tension of 52 dynes/cm. is the lowest clinical value that we have found by this method in more than 100,000 measure¬ ments made during the last 12 years. The first problem concerning the meaning of the different values of uri¬ nary surface tension arose when it was observed that usually the urines with low specific gravity have high surface tension, while those with high specific gravity have low surface tension. The direct correlation between the values of surface tension and specific gravity of the samples thus had to be investigated with the supposition that the amount of water in the urine will have a great influence, by itself, on surface tension. While a correlation between surface tension and water content is often observed,

Google

UNIVERSITY OF MICHIGAr

580

/

RESEARCH

IN

PHYSIOPATHOLOOY

it is not a cause and effect one. Urinary samples with a specific gravity as low as 1.003 were seen with a surface tension of 58 dynes/cm. while samples with a specific gravity as high as 1.030 had a surface tension of 70. Although very seldom encountered, these values have invalidated the sup¬ position that it is the amount of water in the urine which determines the value of the surface tension, so that from the analytical point of view deter¬ mination cannot be substituted. The Nature of the Intervening Substances The existence of several values for the surface tension of urine has sug¬ gested the intervention of different substances in the determination of surface tension. We used the study of the changes induced in the three values of P obtained for a sample. Different repartition capacities were considered as corresponding to different groups of substances. Several methods were used in order to identify these substances. In one method, different constituents of the urine were separated by using solvents or absorbents, or by allowing the constituents to assemble at the surface. The fact that the solvents, if they remain in the fluid even in very minute amounts, influence the surface tension, has largely handicapped their use. However, when lipid solvents were used and could be thoroughly eliminated, the treated urine showed a change in surface tension, especially in Pi values. With the use of activated animal charcoal absorption, all the P values were changed toward higher values. M. Bier in our laboratories has studied the nature of the surfaceactive constituents, separating them from urine by using the fact that they assemble at the surface. Urine was made to foam by passing an inert gas through it. The foam—and, with it, a high proportion of surface-active sub¬ stances was separated. By repeating the procedure, the separation could be pushed far enough so that it could be seen that the ST values, especially those of P3, were influenced. Analyses of the fractions obtained indicated that lipids would intervene in determining the surface tension revealed by the Pj value, while proteins would intervene for the P8, l.e„ after a reparti¬ tion requiring a specific time. We have tried to confirm these preliminary data by adding the agents to urine and following the changes induced. The addition of minimal amounts of soaps to urine has been found to induce a change in all P values and especially in Pi. The addition of billiar salts changed P2 values, while the addition of proteins, such as albumin, influenced the values of P8. It would appear from this preliminary research that while Pi changes are related to an increase in fatty acid derivatives, P2 changes are related more to the intervention of billiar acids, while pro¬ teins and amino acids exert greater influence on the values of P8. This explains why surface tension, corresponding to Plf is still high in urines rich in albumin, and sometimes also in those with billiar acids. It would also explain the observation in the Hay’s Test with sulfur flower in urine, that the sulfur starts to fall quickly if the urine is left standing for a while, but for the same urine this fall occurs only after a certain time if the sulfur is added to urine immediately after stirring. With surface tension

Google

vji luii loi iron I

UNIVERSITY OF MICHIGAN

NOTES

/

581

affected by fatty acids even in minimal amounts, ST changes in relationship to conditions where these substances intervene axe particularly interesting. It is chiefly with these data in mind that we tried to investigate surface tension in relation to normal and abnormal physiology. Surface Tension and Normal and Abnormal Physiology The ability to measure surface tension rapidly and accurately enough, even for very small amounts of fluid, has made it a preferred method for many investigations. In addition to clinical applications, where the infor¬ mation furnished has been especially valuable, we have utilized this method in experiments in animals. Time of the Day and Urinary Surface Tension Urinary surface tension measurements were made in several normal subjects at hourly intervals. In order to eliminate the influence exerted by exercise and food, the subjects were kept in bed for a few hours preceding

Fio. 218. 24-hours hourly urinary surface tension value of a 30-year old normal male, kept resting and with a constant hourly food intake, showing a maximum in the afternoon and a minimum around 5 a.m.

measurements. During this period, and the entire period of the experiment, the subjects were permitted to leave their beds each hour to void. Through¬ out the experiment, they were given the same kind and amount of food each hour. This eliminated as variable the influence of food and activity. Figures 218, 219 and 220 and Table XXVI show samples of the curves of surface tension in such cases. A 24-hour diphasic curve can be noted. Surface tension in mice under similar conditions, however, shows differ¬ ences. A group of 20 mice kept in cages were used. By slight squeezing of

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

582

/

RESEARCH

IN

P H Y S I O P A T H O L OG Y

Fig. 219. Curve of the urinary surface tension in a 26-year old male on standardized hourly food and fluid intake showing a maximum toward the early morning hours and a minimum toward the evening.

the lower abdomen, a few drops of urine were obtained in a little cup and used for surface tension measurement. Changes seen in Figure 221 show that with the passage of time, there is a dampening effect on the curve. This has made us doubt that the intervention of stress in these cases can be re¬ sponsible for the changes. In order to eliminate stress as a factor, a second group of experiments was done in which urinary samples were obtained

Fig. 220. Curve of the urinary surface tension in a 27-year old female on standard hourly feeding, with a maximum in the afternoon and a minimum in the morning.

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

NOTES

/

583

Fio. 221. Average value of surface tension in the urine of 20 mice, obtained every hour, showing variations with a dampening character.

each hour from a different animal. Thus, each animal provided a sample of urine only once and was not under stress. Under these conditions, the dampening effect was not present. A curve showing only two phases in 24 hours was obtained. The ST curves for humans and mice are opposite. During the period when high values occur in humans, low values occur in mice, and vice-versa. Because such opposite variations between humans and mice were found for many other analytical data and were considered related to the nocturnal activity of mice, a third group of experiments was performed in which the mice were kept in darkness during the day and under light during the night in an attempt to change the rhythm of their activity. After three weeks, there were no marked changes in analytical

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

584

/

RESEARCH

IN

P H Y S I O P A THOL OOY

data obtained in these mice. It is possible, however, that more time is re¬ quired to induce changes in surface tension by altering the rhythm of mouse activity. (Fig. 222) Table XXVI

Surface Tension in Normal Healthy 32 Year Old Man and 27 Year Old Female on Standard Hourly Feeding

Hour 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6

a.ra. a.m. a.m. a.ra. a.m. Noon p.ra. p.m. p.m. p.m. p.m. p.m. p.m. p.m. p.m. p.m. p.m. Midnight a.m. a.m. a.m. a.m. a.m. a.m.

Male S.T. in Dynes/cm.

Female S.T. in Dynes/cm.

65 64 65 67 69 70 71 71 71 72 73 73 72 70 69 68 67 67 66 66 65 65 63 64

66 67 67 69 70 70 72 73 73 72 73 72 71 71 70 70 67 67 67 65 65 66 66 65

Surface Tension in Normal Humans and Animals From the first analyses of urinary surface tension in groups of individ¬ uals it could be seen that certain changes common for all were taking place. There were days when all subjects had higher relative values and other days when lower values prevailed. Since there was no common dietetic or habit factor for all the subjects studied, we searched for environmental changes that might be the immediate cause of these variations. In collaboration with P. Teitelbaum we made the following experiment, using 80 rats divided into four groups. One group consisted of females of the Wistar strain and a second consisted of males of the same strain. The remaining two groups were composed of 20 females and 20 males of a black hooded strain. The animals were maintained in groups of five in separate cages on Purina and water ad lib. They were kept in a nonconditioned room. The experiment was conducted for one month, from May to June.

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

NOTES

/

585

Flo. 222. Average hourly values in the urinary surface tension of groups of 5 mice, the group being changed each hour.

Urine was collected in a small vessel by keeping the animal firm and pinching the lower abdominal skin. Surface tension was measured a few minutes later. In each group, animals which did not give urine under this procedure for several consecutive days were replaced by others. Samples of urine were obtained 6 days a week, between 9 and 10:30 in the morning. From the data obtained, an average value was calculated for each group, and the respective values were plotted in curves having the days as abscissae. The values for the female group were higher than for males. No differences were seen between the two strains. And all four curves showed the same variations at the same times. Thus it appeared clear that the variations were related to some external factor acting upon all the animals. We compared the ST curves with others traced for different en¬ vironmental values present at the time of observation. Such values—baro¬ metric pressure, electrostatic value and temperature—were obtained from the Weather Bureau and the curves for the area at the hour of the experi¬ ment traced. Of them all, only the curve for temperature change was signifi¬ cant. The ST was seen to rise each time that the temperature fell and fall when the temperature rose. (Fig. 223) This correlation was further studied by using induced rather than natu¬ ral temperature changes in the following experiment which was made in collaboration with E. F. Taskier. Adult female CFi strain mice were divided into three groups of 20 mice each. They had ad lib access to food and water. One group was placed in an incubator in which the temperature was maintained at 37°C. A second group was kept in a refrigerator at 8°C. The third group served for control and was maintained at ordinary laboratory temperature which ranged between 20-25°C.

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

586

/

RESEARCH

IN

P H YS IO P A TH OLOO Y

Because of the diurnal pattern of surface tension variations, urine speci¬ mens were collected at the same hour every day. During a period of 22 days, daily urine specimens were obtained between 9 and 11 A.M. This was easily accomplished by firmly gripping a mouse in one hand by the scruff of the neck and tail. With the finger of the other hand, the lower

Fig. 223. Comparison between weather data and the average value of the surface tension in 40 male rats and 40 female rats. It shows a relative parallelism with the curve of the barometric pressure and a more consistent relationship with the inverse curve of the temperature.

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

NOTES

/

587

abdomen was gently massaged, causing the animal to void 2-5 drops of urine into a small glass cup. The surface tension of each specimen was determined within a few minutes after it was obtained. The values obtained from day to day were charted for each individual mouse; the average for each group maintained under different temperature conditions also was determined.

Fio. 224. Average value of surface tension of the urine in control mice over a period of 3 weeks.

The average surface tension readings in the control groups are shown in Figure 224. It can be seen that these values fluctuated in an irregular fashion between 58 and 63 dynes/cm. The surface tension values of the group maintained at 37°C show a steady sustained rise from 61 to 65 dynes/cm. (Fig. 225) The mice kept at 8°C showed an initial slight fall in surface tension, with a gradual return to the original levels. (225) After several days in the incubator, the mice began to lose weight, their fur became sparse, and snout areas were constantly wet. The urinary output was scanty as compared with the two other groups. Death began to occur in the mice kept a high temperature on the 12th day. The animals in the refrigerator developed thick luxuriant coats and huddled closely together at most times. None died from exposure to this temperature. The fact that the animals maintained at 37°C showed a steady rise in urinary surface tension was especially significant. As expected, the urine of these animals was scanty and more concentrated than for the other groups. With this diminution in volume, it would be expected that the concentration of surface-active substances would rise and the surface tension would be lowered. The fact that the exact opposite occurred indicates that the ob¬ served change has to be considered as an effect of the high temperature. This appears especially interesting for the relationship between tem¬ perature and the two ST patterns. While higher temperature induces one

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

588

/

RESEARCH

IN

P H Y S I O P A TH O L OOY

Fig. 225. The average values of the urinary surface tension of 20 female mice kept in the incubator at 37#C. and of 20 female mice kept in refrigerator at 8*C. The values are progressively increasing for the animals kept in the incubator until the animal died. For the animals kept in refrigerator, after an initial descent, the values ascend toward normal.

pattern, cold induces the other. It must be noted that the organism cannot defend itself against the pattern induced by higher temperature and the animal dies after a certain time, but for the pattern induced by cold, de¬ fense is possible. The body seems to be able to overcome the change. The surface tension returns to normal and the animal becomes adapted to the temperature. Not one of the animals kept in the refrigerator died, while all in the incubator were dead after a month. Adrenalectomy induces an im¬ mediate increase in the surface tension of the urine. (Fig. 226)

Fig. 226. The surface tension of the urine increases to high values after adrenal¬ ectomy.

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

NOTES

/

589

Fio. 227. Curve of the surface tension changes in urine specimens of a 36-yr. old pregnant woman shows a manifest change toward low values, starting with the 4th month, and becoming especially low in the last three months.

URINARY SURFACE TENSION (Dynes/cm) Fio. 228. The average value of the surface tension in pregnant women shows a manifest change toward low values.

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

590

/

RESEARCH

IN

PHYSIOPATHOLOGY

Colloids in Urine and Surface Tension An interesting relationship between urinary surface tension and the presence of “colloids” in the urine was noted by Butt and his associates. (240) Using the pendant drop method for the ST, direct examination in dark field for the presence of colloids in the urine, electrophoresis for de¬ termination of electrical charges, and the study of evaporated urine smears, they showed that urines with a high content of colloids, have a low ST; those with a low colloid content, a high ST. They have further correlated a low amount of colloids with a tendency of urine to precipitate and form stones. (242) They examined the colloid particles in the urine of different groups of individuals and found them high in Negroes, and especially high in pregnant women, which is in accord with the low surface tension of the urine which we found in these cases (Figs. 227 and 228) and the low tendency of both groups to form urinary stones. We were interested in the relationship between variations in the urinary content of colloids and systemic patterns corresponding to high and low ST. R. Ravich in our laboratory has confirmed the correlation between presence of colloids and ST by using our urotensiometer. (219) Chapter 4, Note 12. Urinary Oxidoreduction Potential For the study of the oxidoreduction potential of the urine, we used a Beckman pH meter with platinum electrodes. We measured the potential at the pH of the sample and also at pH 7. For this purpose, the platinum and the respective calomel electrodes used for these measurements were introduced into the beaker of the Fisher titrimeter together with the elec¬ trodes of the potentiometer. After stirring, the pH of the sample and its oxidoreduction values were measured. The pH then was brought to 7 with HC1 or NaOH solution, and the value of the oxidoreduction potential was again measured. Four values were thus obtained: the original pH, the titrimetric acidity or alkalinity, and the oxidoreduction values at the origi¬ nal pH and at pH 7. Figures 229 and 230 show a sample of such curves. Chapter 4, Note 13. Oxidoreduction Potential of the Urine We have tried to determine the oxidoreduction potential of urine samples by using the change of a color indicator in its leuco base. We chose toluidine blue which, with a rH2 of 14, is at the middle of the scale of the rH2 values. In order to eliminate two of the important factors which inter¬ vene in the oxidoreduction potential—differences in pH and temperature —we used a fixed temperature and very low pH. The degree of oxidore¬ duction potential was determined by the time necessary to obtain the dis¬ coloration for a standard amount of the color indicator. The reactive used was a solution of toluidine blue in a normal solution of hydrochloric acid. The amount was chosen so as to give a discoloration at 100 seconds for the normal individual. 1.5 cc. of a saturated solution of toluidine blue in al-

D.gitized by GOOglC

UNIVERSITY OF MICHIGAN

NOTES

/

591

A. L.

Fio. 229. The curve of the oxidoreduction potential of the urine measured electri¬ cally. The curve of the measurements made directly on the urine (El) show big vari¬ ations which are smaller if the pH of the sample is brought to 7 (E2). In a case of cancer of the breast, the curve remains constantly below the 0 value.

Fio. 230. Curve of the oxidoreduction potential values of the curve brought to pH 7 of a case of cancer of the breast, shows values around or above the 0 value.

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

592

/

RESEARCH

IN

P H Y S I O P A T H OLOOY

cohol was added to 100 cc. of n/10 hydrochloric acid. 1 cc. of this reagent was added to 4 cc. of urine in a test tube kept for a while in boiling water. The time necessary for the discoloration was marked. Values as low as 3-4 seconds or as high as above 420 seconds were seen. A high oxidoreduction potential inducing a rapid discoloration was found to correspond to a pat¬ tern of the offbalance type A while a low discoloration was seen to corre-

Days Fio. 231. Curve of urinary oxidoreduction values in a case of carcinoma of the breast with multiple bone metastases. The values are established as the time neces¬ sary to obtain the reduction at 100*C and with a pH around 2, of a solution of toluidine blue so chosen as to have 100 seconds as the average value for groups of normal individuals. In this case the values remain fixed low below 100 seconds, cor¬ responding to a pattern, of the offbalance type A.

spond to the pattern of type D. Figures 231 and 232 show two such curves. We used this test for many years as main analyses to determine the exist¬ ing offbalances. (220) Chapter 4, Note 14. Peroxides in the Urine The hypothesis of the existence of a phase “oxygen’* of offbalance D led us to study the appearance in urine of products resulting from abnormal oxidation. We were especially interested in the existence of substances hav¬ ing peroxide properties. We found that addition of sulfuric acid to urine of certain subjects induced appearance of indigotin and indigo-rubin. In order to investigate the reaction, we have utilized the solubility of indigotin and indigo-rubin in neutral solvents. Through their extraction it appears possible first to prevent their transformation in colorless isatin and, second,

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

NOTES

/

593

to evaluate the relative amounts when they appear during the reaction. To 4 cc. of urine, one centimeter of toluene was added. After shaking the mix¬ ture, 1 cc. of pure sulfuric acid was added and the mixture was immediately shaken again. When the mixture was allowed to stand, the toluene sepa¬ rated and its color, blue or violet, indicated the presence and also the rela¬ tive amounts of indigotin and indigo-robin. Another method used to detect peroxides was the acidification of urine followed by addition of potassium iodide. For iodometric evalution, starch

Days

Fio. 232. The urinary oxidoreduction values in a case of cancer of the colon with abdominal metastases. The values remain the whole time above 100 seconds, cor¬ responding to the pattern present in the offbalancc type D. solution was added. The amount of iodine liberated could be determined titrimetrically. The form in which peroxides are present in the urine is not clearly es¬ tablished. Although the distillation of the urine gives peroxides in the first distillate, these are not in the form of hydrogen peroxide, since catalase does not induce their disappearance. The values obtained with both meth¬ ods, sulfuric acid and iodometric, are relatively parallel. The sulfuric acid method, however, produced a higher percentage of positive results. The presence of slight amounts of peroxide in the urine has been found in about 3% of normal subjects. In contrast, we found peroxide in the urine of 87% of a group of 27 schizophrenics studied through daily analyses over a period of three years. In some of the subjects, throughout the entire three-year period with more than 1,000 analyses, not a single negative re¬ action was seen. (Fig. 233) (221, 222) We have also found positive reactions during streptococcic infection,

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

594

/

RESEARCH

IN

PH Y SI OP A TH O L OGY

erysipelas or tonsillitis. In radiation sickness the reaction is positive espe¬ cially when tissue lesions are manifest such as mucositis or epidermitis. In general, treatment with selenium has given a relatively high proportion of positive results, especially at the beginning of treatment. While positive re¬ action appeared to be consistent with a favorable evolution of tumors, an extremely intensive reaction appeared related to a bad prognosis. The fol¬ lowing observation is characteristic.

Fio. 233. The reaction for peroxides remains consistently positive in the urine of a schizophrenic in daily analyses during a period of 3 years. (Part of the curve.)

Mrs. N. C., 28 years old, with Hodgkin’s disease, had received three treatments of teleradiotherapy, with the general condition completely un¬ changed. The patient presented an extremely intensive urine peroxide re¬ action. Dilution of the urine to 1/50 still showed a marked blue color after treatment with sulfuric acid and toluene. We informed the attending physi¬ cian about the finding and advised the discontinuance, at least for the mo¬ ment, of the treatment. The perfect general condition of the patient induced the radiologist to disregard our advice. A new treatment of teleradiotherapy was administered. Three hours later the patient, who only that morning had been shopping, went into a shock and died during the night. We want to emphasize, however, the correlation between the lack of peroxides in the urine and a poor prognosis during radiotherapy. The cases in which a positive reaction disappeared, were always followed by a change for the worse in the general condition. The persistence of this lack of peroxides was seen in the cases with a rapid lethal termination. Chapter 4, Note 15. Index of Excretion and of Retention One of the most important aspects of the relationship of an entity to its environment is given by its intake and output. The concept of hierarchic organization with emphasis on the individuality of the entities, has given a special meaning to the study of these processes. For each entity its proper environment is represented by the secondary part of the entity immediately superior to it. The nuclear sap represents thus the environment from which the chromosomes take the material necessary for their metabolism and where they reject these substances which are no longer needed. Similarly, the cytoplasm represents the environment for the nucleus, the interstitial fluid for cells, the lymph for tissues, the blood for organs and the actual environment for the organism. This systematization, based on the organiza¬ tional individuality of the entities, has guided the study of the relationship

Google

UNIVERSITY OF MICHIGAN

NOTES

/

595

between entities and their environments under normal and abnormal con¬ ditions. It is under this aspect that we have investigated the renal excretion, which according to the hierarchic organization, corresponds to the relation¬ ship between the organism as an entity and its environment. Some of the substances excreted come from the metabolism of lower entities. Related to blood, they would represent often noxious undesirable substances, if the higher mechanism of the blood would not intervene. Al¬ though that which we see as urine is the result of the relationship between the organism as an entity and its environment, the origin of the different substances forming it, as related to the different other levels, has to be considered. While for certain elements this origin is evident, for many sub¬ stances only suppositions are available today. When a systematic analysis of these constituents was attempted, other difficulties arose. The isolated urine samples easily available, have only a very relative value for many of these investigations. The titrimetric data expressed as concentration of various substances are all functions of the amount of water eliminated in the sample. As this often varies widely, the informations obtained are only relative. Balance analyses concerning entire intakes and outputs represent such technical difficulties as to make them unavailable for routine investigation, in which hundreds of subjects are daily studied. We tried to bypass this difficulty by eliminating the factor water excretion, from the considered data. The fact that the concentration of a substance and the specific gravity of the urine, are both direct function of the amount of water present, has permitted to eliminate this factor. The ratio between them appears thus independent of the amount of water present. It relates the amount of a substance to that of the bulk of the substances eliminated through the kidney. An index of excretion was thus obtained by dividing the concentration of the substance by the specific gravity. The opposite ratio would correspond to an index of retention. From the physiological point of view, these ratios are not affected by the factors which govern the glomerular filtration, which are acting similarly for all the substances present. They are little or not affected also by the back resorption, where the differences between the various substances are reduced. They will show consequently, big variations as resulting from the active reabsorption, which takes place in the distal portions of the con¬ voluted tubes. It is this character which gives the indexes of excretion or retention, as we calculate them, their value. We have utilized for years these indexes for chlorides, sodium, potassium, phosphoric ion, sulfhydryl, calcium, to obtain valuable information which otherwise could not be furnished by the simple analysis of the isolated urine samples. We will come back to these indices during further analyses. Chapter 4, Note 16. Water and Nitrogen Metabolism The analyses of different urine samples have shown that the amount of water present in urine seems to influence indirectly its constitution. It could thus be seen that while very diluted urine, corresponding to a large

Google

UNIVERSITY OF MICHIGAN

596

/

RESEARCH

IN

PHYSIOPATHOLOOY

amount of water excreted, is usually alkaline, concentrated urine, cor¬ responding to small amounts of water excreted, is generally acid. Further¬ more, it could be seen that these changes are related to more profound metabolic differences. When related to the nitrogen metabolism, it could be seen that diluted urines are rich in free ammonia while concentrated urines in uric acid. We have thus investigated the relationship between these two factors, the amount of water excreted and the form under which the nitrogen is eliminated. The comparative physiology shows us that the manner under which nitrogen is excreted varies for different animals according to the amount of water available in the surrounding environment. In fish, with water almost unlimited, nitrogen is excreted in the form of ammonia. The high toxicity in this form of nitrogen excretion is counter-balanced by the amount of water in which the excreta are diluted. Fish are ammonioselic. In ter¬ restrial mammals, where the amount of water available is more limited, the excretion of nitrogen is made in the form of urea which is much less toxic than ammonia. The danger of poisoning the drinking water through excreta is thus reduced. Mammals are ureoselic animals. For birds, for whom water is scarce, the form of nitrogen excretion is of uric acid, which through its low solubility in water, has little chance to contaminate the drinking water. Birds are uricoselic. Based on this relationship between water avail¬ ability and the type of nitrogen excretion, we looked for a similar relation¬ ship in humans between the excretable amount of water and the type of nitrogen metabolized under normal and abnormal conditions. An immediate confirmation was obtained in those abnormal conditions where the amount of water excreted is abnormal. As already seen above, in subjects having a high diuresis, which in general would correspond to a high amount of water available to be excreted from the body, the urine is usually alkaline, the alkalinity due to ammonia. On the opposite side of the normal, there are subjects with a very reduced urinary excretion. In patients eliminating only two to three hundred cc. in 24 hours, the amount of uric acid in the urine is manifestly increased. Upon standing, these urines always show a reddish deposit formed mostly by uric acid. Relating this to comparative physiology, while the normal subjects would appear ureoselic, those with polyuria can be considered as ammonioselic and those with oliguria, uricoselic. We tried to see if a change in the form under which the nitrogen is eliminated can be induced by changing the amount of water available to be excreted. Normal subjects whose urines were tested for certain periods of time for their content of ammonia, urea and uric acid, were given 1 to 2 liters of water to drink. The highly diluted urine which was subsequently excreted, became alkaline. The total amount of ammonia increased while urea and uric acid were slightly reduced. The same subjects were later given a dry diet for 12 hours or more. The specific gravity of the urine in most of these cases was above 1.026, indicating a kidney with normal con¬ centration capacity. Although the content in ammonia decreased manifestly in these urines, the increase in uric acid excreted was minimal. We sub-

Google

CHIGA

NOTES

/

597

mitted the same subjects to a diet with fluids reduced to a minimum, for 3 to 4 days. Under these conditions, the excretion of uric acid started to increase. Great intake of water would thus transform a normal ureoselic in¬ dividual into an ammonioselic in only a few minutes. A similar passage into uricoselic was seen to need days, and even then it showed only minimal changes. This can be explained by the fact that while ammonia in urine appears largely through changes taking place in the kidney cells themselves, uric acid results from more profound metabolic changes, which concern especially the nitrogenous bases, particularly the purines. Chapter 5, Note 1. Second Day Wound Crust pH The metabolic processes characterizing abnormal foci have been investi¬ gated in various ways. One method was devised in order to study the acidbase changes which take place within abnormal foci created by surgically produced wounds under the influence of various chemical, physical and bio¬ logical factors. This research was made in collaboration with C. HuescaMejia. (212) Adult Carworth Farm female and male albino rats weighing 150 to 200 grams were employed. The animals were separated according to sex and all received a standard diet of Purina Chow and water ad lib. Tests were run on groups of twenty animals, with from two to four control ani¬ mals in each group. The animals were divided into groups that were subjected to various experimental conditions for three days, after which time, under ether anes¬ thesia, a wide area of the back of each animal was carefully depilated by hand. A 1 square cm. wound was then produced in the depilated area down to the dorsal aponeurosis. The wound was kept free of blood with dry gauze until bleeding had entirely ceased, and was then left uncovered. All wounds were made between 8:00 a.m. and 10:00 a.m. A glass electrode made according to the specifications of Mclnnes and Dole (223) was used. As reference, an electrode containing normal saline was employed. (224) The electrodes were mounted on a stand in a fixed position. A model H Beckman pH meter, whose signal was amplified by a 6H6 and 6SN7 push-pull, was used as the first amplifier. The readings were made on a 200 micro-ampermeter adjusted so as to have the full scale represent one pH unit. The experimental error using this apparatus was found to be less than ± .01. pH determinations were carried out by bringing the wound area into contact with the tips of the electrodes. The animals were held gently but firmly in one hand until they were completely immobile, at which time a firm contact was established between the center of the wound area and the tip of the glass electrode, and between the reference electrode and the wound periphery. Readings were carried out on the surface of the freshly exposed aponeurosis within ten to fifteen minutes after the surgical pro¬ cedure. Subsequent readings were made every twenty-four hours upon the wound crust, which was washed and then moistened with a drop of an

Google

unnina rrom

UNIVERSITY OF MICHIGAN

598

/

RESEARCH

IN

PHYSIOPATHOLOGY

0.1% sodium chloride solution freshly adjusted to pH 5 as suggested by Blank for use in skin pH determinations. (225) The electrodes were standardized with buffers of different pH before and during each period of testing. The effect of various chemical agents upon the wound pH was studied by daily oral administration for three days preceding the operation and thereafter until the conclusion of the series of pH determinations. In general, the substances were administered according to weight in quantities corre¬ sponding to the therapeutic doses accepted for humans or in amounts equal to 10% of the daily toxic dose. Water soluble substances were ad¬ ministered in drinking water. Oil soluble substances were administered on pieces of bread. In some cases, substances were introduced directly into the stomach through a catheter. In a few cases, substances were injected subcutaneously. In the 164 control animals, the pH of the wound surface varied between 7.30 and 7.33 when measured ten to fifteen minutes after the completion of the surgical procedure. The pH remained at this level for at least three hours. Twenty-four hours after the wounds were produced, the pH of the moist crust covering the area was found to be between 7.72 and 7.76 in all untreated animals. (Fig. 234)

Fig. 234. Second day wound crust pH values remain in a range from 7.72 and 7.76 in normal rats as seen in the animals which served as controls for the multiple experi¬ ments.

At forty-eight hours, the pH of the crust was found to be between 7.42 and 7.60, this being the period of greatest variability. At seventy-two and ninety-six hours, all the readings were between 7.28 and 7.32. After the fifth day, similar values were found and further readings were not taken. No consistent correlation was found between the values on different days for individual animals. For example, in some animals with a wound pH of 7.30—the lowest value—immediately after the operation, pH reached 7.76, the highest value for the normal range, in twenty-four hours. In males, values appeared to be slightly higher than in females.

Digitized by

Google

Original from

UNIVERSITY OF MICHIGAN

NOTES

/

599

In 410 of the 860 animals exposed to various chemicals pH value of the wounds was determined several minutes after the operation and found to be between 7.28 and 7.35. Only 22 showed a deviation from the control range of 7.30 to 7.33. No correlation was observed between the minimal changes in these animals and the type of treatment administered. While the pH values found several minutes after wound induction showed very little or no variation from the control range and no correlation with the various experimental conditions employed, the findings at twentyfour hours showed considerable significance for the agents used. At fortyeight hours and thereafter, no important differences were observed between values for controls and those for groups treated in different ways. In con¬ tinuing these studies therefore, determinations were carried out only several minutes after the production of the experimental wounds and then again 24 hours later. Actually, only values for the twenty-four hour reading ap¬ peared significant and will be discussed. We made 24 hour measurements for all of the 860 animals treated with different agents. For convenience, we refer to the pH value of the crust at twenty-four hours after creation of the experimental wound as the s.d.c. pH (second day crust pH). From four to twelve animals were employed in the assays of the activity of each agent. By applying the same experimental conditions to animals in groups tested at different times, it was possible to determine whether the changes observed were due to some external factor such as temperature, humidity, etc., or were actually due to the imposed experimental condi¬ tions. The s.d.c. pH has proven to be of considerable interest because consistently similar changes have been found to be produced by the same agents when applied to animals in different groups tested weeks or months apart. Considering all the animals treated with various agents, three possibili¬ ties have been found to exist: 1) There may be no effect upon the s.d.c. pH, in which case the values will all fall within the control range of 7.72 and 7.76 found in untreated animals; 2) s.d.c. pH may be elevated to values between 7.77 to 7.85; or 3) the s.d.c. pH may be reduced to values of 7.70 to 7.60. We will present here only the conclusions of these studies as related to the various agents investigated. CHEMICAL FACTORS Cations and Anions It was interesting to investigate the influence exerted by some cations and anions by first using the same anion with various cations and then using different anions with the same cation. It was apparent in all the ex¬ periments that the immediate pH of the wound does not differ from that of the untreated animals, and that the s.d.c. pH data obtained are concordant. We studied the influence exerted by anions first by investigating the effects of administration of acids. With even strong inorganic acids, no

Di 9'tized by GOOgle

UNIVERSITY OF MICHIGAN

600

/

RESEARCH

IN

PHYSIOPATHOLOGY

changes were seen in the normal tissues. Definite and opposite effects were thus obtained with acids corresponding to the elements of the Vllth series and with those of the Vlth series. The first group of acids, especially HC1, induced a frank acidifying effect while the second produced an alkalizing effect. The phosphate and nitric ions showed strong acidification, the iodide and bromide ions were weaker than the chloride ion. The bicarbonate ion clearly alkalized, as did sulfate and selenate. The thiosulfate ion had an obvious alkalizing effect, with pH values as high as 7.85. Among the or¬ ganic acids, citric acid produced one of the strongest effects, even stronger than that of the inorganic acids. The fact that citric acid is only slightly metabolized could explain its strength. The gluconate ion induced a slight acidification. The cacodylate ion seemed to induce no changes although not enough animals were utilized to judge its effect thoroughly. In studying the effects of salts, the roles of both cation and anion were considered. Using different anions for the same cation, it was possible to judge the effect of the cation. Sodium and lithium produced relatively slight acidification. Potassium manifestly acidified as did ammonium, the latter, however, to a less marked extent. Marked acidifying effects were seen for iron, mercury and bismuth. A lesser effect was obtained with molybdenum and aluminum. On the other hand, a manifest alkalization was found for bivalent calcium, strontium, copper, barium and cobalt. Manganese and silver cations seemed to in¬ fluence the second day wound pH only slightly toward alkalization. It seems that there is an additive effect for the different elements in their acidifying or alkalizing influence. This has permitted us to judge the effects of the different ions. Potassium induces greater acidification than sodium, and still greater acidification than ammonium. Potassium chloride, in which the two ions have an additive effect, is thus more frankly acidify¬ ing. The same is true for the acid phosphate. The alkalizing tendency of sulfate ion opposes the acidifying effect of potassium and explains the slight acidifying influence of potassium sulfate. We must arrive at the relatively strong alkalizing tendency of the carbonate ion to find an anion able to counteract the acidifying effect of potassium. The s.d.c. pH effect of potas¬ sium carbonate is in the normal range. The data obtained through this study led to the research on the intervention of the elements in biology, which is the subject of Chapter 5. Information concerning the effect upon the s.d.c. pH of these elements as well as the relationship between this effect and the structure of the elements is discussed in this chapter. Calcium ion has an alkalizing influence strong enough to counteract the acidifying tendencies of such anions as chloride and phosphate. Weaker acidifying anions, such as lactate and gluconate, are not sufficiently strong to counteract the alkalizing tendency of calcium, and calcium salts of these acids have a strong alkalizing effect. This analysis indicates that the effect of a salt upon the local pH of abnormal tissues can be judged by considering the additive influence exerted by anion and cation, the effect increasing if both have tendencies in the same direction, and decreasing if the tendencies are opposed. We will not

Google

NOTES

/

601

emphasize here the other antagonistic biological effects of cations and anions, as they pass from acidifying (citric acid and potassium) to alkal¬ izing (calcium and thiosulfate). We will discuss these effects in connection with the pharmacological studies of these agents. For the moment, we want only to emphasize the value of this investigational method. Acid Lipoids

The next step in the use of the s.d.c. pH was the study of the effects of a special group of acids in which we were interested, the fatty acids. Analy¬ sis of the results obtained clearly shows the importance of the nonpolar group. A carboxyl, when bound to a long chain as in the fatty acids, does not by itself seem able to induce a change in the second day wound crust pH, the values remaining in the normal range. The substance appears in¬ active when the nonpolar group does not have its own energetic center or formation. The saturated fatty acids with 10-16 carbons do not influence the s.d.c. pH. The presence of double bonds in the nonpolar group changes the influence exerted. All the nonsaturated fatty acids studied show an alkalizing effect, with relatively slight differences for the higher desaturated members such as linolenic or arachidonic fatty acids, or for the fatty acid mixture obtained from cod liver oil. However, the conjugated fatty acids studied, such as eleostearic acid, or the mixture of acids starting from cod liver oil, showed the highest values in this group, even for so small an amount as 5 mgr. per animal per day. These data indicate the role of ener¬ getic formations in the nonpolar groups of fatty acids. We must emphasize the difference between the hydrosoluble organic acids and the group of fatty acids mentioned above. In the former, the action seems due to the intervention of the carboxyl, probably explaining the strong activity of tricarboxylic citric acid. With an important nonpolar group, this carboxyl seems to be unable to carry the molecule, and there¬ fore cannot act. The intervention of a double bond could serve in two ways: 1) by bending the molecule, thus increasing its mobility as it also reduces the melting point; 2) as an energetic center where reactions take place. The fact that the 10 carbon lauric acid is inactive would indicate the slight influence to be expected from the bending of the molecule alone, as in oleic acid. The influence exerted by metabolic changes in which fatty acids intervene through the energetic centers in the nonpolar group explains the fact that they have a local alkalizing effect instead of the acidifying effect of many other organic acids. (Fig. 235) A Icohols

The role of the relationship between polar and nonpolar groups ap¬ peared very clear in the study of the series of aliphatic alcohols. We have considered separately a group of agents extensively used in our research. These are organic substances that have a radical with a bivalent sulfur as the polar group. We have mentioned above that an inorganic substance with similar constitution, sodium thiosulfate, has a strong alkalizing effect upon the s.d.c. pH. Such an effect upon the s.d.c.

*d by

Google

UNIVERSITY OF MICHIGAN

602.

/

RESEARCH

IN

PHYSIOPATHOLOGY

pH has been obtained with all preparations containing a polar thiol group when administered orally or parenteraUy. We must emphasize the unusual uniformity of results, rarely encountered in other biological experiments. It appears that the alkalizing effect of these preparations is sufficient to override the individual differences in subjects receiving them. The same alkalizing effect has been apparent for sodium thiosulfate, and seems to be a common characteristic for substances having a bivalent sulfur in their polar group. These alcohols exert no influence upon the pH of normal tissues, as seen in measurements taken immediately after the skin is cut. The first members of the series, the methyl to propyl alcohols, do not influence the

Fio. 235. The administration of various lipoacids upon the s.d.c. pH shows that while the saturated fatty acids do not influence it, the non-saturated fatty acids as well as the lipoacid preparations obtained from different sources induce an elevation of the local pH.

s.d.c. pH. From butyl alcohol to nonyl alcohol, the members of the series show a consistent acidifying influence. However, a very important obser¬ vation was made when the four isomers of butyl alcohol were studied. Three showed the acidifying effect while one, the tertiary isomer, like the lower alcohols, did not influence the second day wound crust pH. This could be correlated to a special characteristic of these substances, their relative solubility in water and in neutral solvents. Just as do the lower alcohols, tertiary butyl alcohol mixes with water and neutral solvents, while the other three butyl alcohols, like the higher members of the series, are more soluble in neutral solvents than in water. (Fig. 236) This character¬ istic, which was used in systematizing the polar-nonpolar substances, ap¬ pears to determine the activity of the aliphatic alcohols upon the s.d.c. pH. We must again emphasize that this activity is not direct but influences cer¬ tain metabolic processes, since the active alcohol induces local acidifica¬ tion rather than the alkalization to be expected with a direct effect.

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

NOTES

/

603

Another factor which seems to influence the activity of this alcohol series is the length of the carbon chain. While heptanol induces the char¬ acteristic acidification, octyl alcohol does so in only some animals. Nonyl and decyl alcohols appear inactive. The possibility of a biological competition between these agents and fatty acids has led to research with other alcohols capable of combining with fatty acids, particularly in vivo. We studied glycerol, glycerophosphoric ion and sterols, which are frequently found combined with fatty acids. We added glucose to this group because of its metabolic relationship to glycerol derivatives, although it is apparently not related to fatty acids. It is interesting to note that glycerol produced only minimal influence upon the immediate pH. The highest values were still in the normal range. The acidifying effect of glycerol upon the s.d.c, pH, seemed to be subject 7 06

7 04

Ala wot:

7 82 7 00 7 78

7 7647 74

/

d

— —

o o o o o «o © o q r^dodridasr^oo

8

so — 00 fs 00 oo

»

so SO — SO

8888858

Google

Original from

UNIVERSITY OF MICHIGAN

NOTES

/

699

Conjugated Fatty Acids and Quenching

Nonconjugated fatty acids such as linoleic acid, linolenic acid, arachidonic acid, mixed fatty acids from body liver oil and cod liver oil have a limited quenching action. Conjugated dienes such as isomers of linoleic acid or conjugated trienes such as eleostearic acid obtained through con¬ jugation of linolenic acid or extracted from China wood oil also have a limited quenching effect upon hydrocarbon carcinogens and related com¬ pounds. (Table XXXVII) The same is true for mixtures of conjugated dienes and trienes.

Fio. 281. Spectral analysis of conjugated cod liver oil fatty acids shows the presence of conjugated di-, tri-, tetra-, penta- and hexaenes.

Fatty acid mixtures having conjugated di-, tri-, tetra-, penta- and hexaenes as shown by spectral analysis (Fig. 281) have been found to ex¬ hibit a high degree of quenching activity (Fig. 282) (Table XXXVII) when mixed with hydrocarbon carcinogens. The quenching action of fatty acids upon the fluorescence of hydro¬ carbon carcinogens appears to be nonadditive. When the incident ray is passed first through an 0.2% solution of conjugated fish oil fatty acids in alcohol and then through an 0.012% solution of methylcholanthrene in alcohol in separate vessels, the residual fluorescence is 81%. When the same two solutions are mixed together in one cell, the residual fluorescence is 11.2%.

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

700

/

RESEARCH

IN

P H YS I O P A T H O LOG Y

The relationship of the different conjugated members to the quenching effect has been studied. Fatty acid mixtures having different proportions of isomers with 2, 3, 4, 5 and 6 conjugated double bonds were obtained by conjugation or by treatment of conjugated mixtures with heat, oxygen. Quenching

effect

Fig. 282. Quenching of fluorescence of a methylcholanthrene (.0062% ) solution in

alcohol by different concentrations of conjugated fish oil fatty acids.

chlorine or sulfur. Changes in the proportions of the di-, tri-, tetra-, pentaand hexaenes were followed by means of spectral analyses. The changes in the height of the peaks in these curves corresponding to the different con¬ jugated polyenes were then compared with the changes in the quenching effect of the corresponding fatty acid mixtures. Figure 283 shows the spec-

Digitized by

Goo

Original from UNIVERSITY OF MICHIGAN

NOTES

/

701

tral analysis of samples obtained at various intervals during the action of oxygen upon a mixture of conjugated fatty acids. As seen, oxygen induces unequal changes in the height of the peaks in the curves of which corre¬ spond to di-, tri-, tetra-, penta- and hexaenes. Fig. 284 shows the quenching activity of the mixtures. It can be seen that a parallelism exists between the relative proportions of the tetraenic component and the quenching activity of

Fig. 283. Changes in the absorption spectra of a mixture of conjugated fish oil fatty acids induced by treatment with oxygen. The treatment has a greater effect on the higher unsaturated members, with the proportion of tri-, tetra-, penta-, and hexaenes decreasing as treatment continues, as seen by the reduction in the height or even dis¬ appearance of the peaks. After 12 hours of treatment, the conjugated dienes are the only ones not yet influenced. Dilution 0.002% in ethyl alcohol.

the mixtures. In this experiment it appears that the quenching effect could also be related to the presence of conjugated pentaenes. Evidence available from other experiments do not, however, sufficiently support this. We studied in a similar way the effect induced by the treatment—with sulfuric acid—of a mixture of conjugated fatty acids of cod liver oil. Fig. 285 shows part of the occurring changes and Fig. 286, the quenching effect. Similarly, we studied the changes in the quenching effect during the conjugation with KOH of cod liver oil fatty acids in ethyl alcohol. Fig. 287

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

702

/

RESEARCH

IN

PHYSIOPATHOLOGY

Residual

Fluorescence

Fio. 284. The relationship between changes of the di-, tri-, tetra-, penta- and hexaenic peaks as found on spectral analysis of samples of conjugated fish oil fatty acids treated for different lengths of time with oxygen and the quenching effect of the same samples. A close parallelism exists between the decrease in the proportion of tetra- and pentaenic peaks and the quenching activity of the mixture.

shows the conjugation effect and 288, the quenching effect of the prepara¬ tion at different moments, in various dilutions. The entire problem was simplified by studying a pure conjugated tetraene. We have obtained pure tetraenic parinaric acid from akariton fat

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

NOTES

/

703

of Parinarium laurinum seeds. In addition, we have prepared almost pure tetraenes utilizing the technique described by Maury, Brode and Brown. Unfortunately, with the last method, the results were less favorable, the proportion of tetraenes beginning to decrease long before the conjugated dienes and trienes have disappeared. Pure tetraenic conjugated acid has shown that the quenching action is related almost entirely to the tetraenic component alone, and in a mixture it is largely parallel to the content in conjugated tetraenic fatty acids. Fig. 289 shows the quenching curve in¬ duced by parinaric acid.

Fig. 285. The changes in the spectral analysis of a mixture of conjugated cod liver oil fatty acids, induced by the treatment with sulfuric acid. The treatment leads to unequal decrease in the amount of different conjugated members. Only two curves are shown: at the beginning of the treatment and at 260 minutes.

Conjugated Fatty Acids and Induced Carcinogenesis

We have investigated the influence exerted by the fatty acids—conju¬ gated or not, and their mixture, upon the induction of tumors by carcino¬ gens. From the various experiments, some were eliminated, either because the dose of methylcholanthrene employed did not produce tumors in a sufficient number in control animals to permit any conclusive comparison, or the death rate from intercurrent causes was abnormally high so that the entire experiments had to be discarded. The experiments that were satisfactorily completed are summarized

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

704

/

RESEARCH

IN

PHYSIOPATHOLOGY

in the following three tables. In the first group of experiments (Table XXXVIII), 4 groups each composed of 40 adult Swiss mice (20 male and 20 females in each group) were employed. Each animal received in the right flank a single subcutaneous injection 0.2 mg. of methylcholan-

Fio. 286. The changes in the quenching of the treated mixture parallel the changes induced in the amounts of conjugated tetra-, penta- and hexaenes.

Digitized b

Google

Original from

UNIVERSITY OF MICHIGAN

NOTES

/

705

threne as a 0.2% solution in tricaprylin. These animals also received subcutaneous injections of a mixture of fatty acids extracted from cod liver oil, or a mixture of cod liver oil fatty acids conjugated by treating them with KOH. The fatty acids were administered as a 5% solution in cotton-

Fio. 287. Spectral analyses of fatty acids of cod liver oil, treated with KOH in ethyl alcohol. They show the appearance of high amounts of tetra-, penta- and hexaenes.

seed oil. Animals treated with fatty acids received 0.3 cc. of this solution in the contralateral side twice a week for three months. The control ani¬ mals received the same volume of cottonseed oil in the same number of injections. In addition, one group of animals treated with the conjugated fatty acids received four injections during the two weeks preceding the

Table XXXVIII Died Treatment Without Tumors 10 Cottonseed oil-controls Fatty acids from cod liver oil 3 Conjugated fatty acids from 6 cod liver oil Conjugated fatty acids from 14 cod liver oil (•)

%

Tumors 12/30 18/37

With Tumors 40 48

7/34

20

3/26

11

* Received 4 injections of fatty acids before methylcbolanthrene was administered.

Digitized by

Goo

UNIVERSITY OF MICHIGAN

706

/

RESEARCH

IN

P H YSI OPA THO LOGY

Fig. 288. Changes in the total quenching capacity of samples of cod liver oil during isomerization with KOH in ethyl alcohol. While the quenching effect is reduced— even for high concentration—for the sample having only Vi hour of conjugation, it is high for that obtained after 24 hours. It remains almost the same for the sample after 84 hours of conjugation. The quenching appears related to the presence of conjugated isomers, with 4 or more double bonds.

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

NOTES

/

707

Fkj. 289. Quenching effect of parinaric acid upon the fluorescence of methylcholanthrene. The relationship between the quenching effect and the presence of conjugated tetraenes is seen in the fact that parinaric acid has a quenching effect of 96.2 for a dilution of 0.006% and still one of 62% for a dilution of 0.0002%.

Digitized by

Goo

Original from

UNIVERSITY OF MICHIGAN

708

/

RESEARCH

IN

PHYSIOPATHOLOGY

methylcholanthrene injection. Thirty-three animals died without tumors during the course of the experimental period. The number of animals sur¬ viving for five months plus the number in which tumors developed during this period of time are listed for each group. In a second group of experiments (Table XXXIX) six groups of 40 mice each received one subcutaneous injection of 0.25 mgm. of methyl¬ cholanthrene of an 0.2% solution in tricaprylin and a second similar injec¬ tion one week later. Groups were treated twice weekly for three months with 0.3 cc. of 5% solutions of the following fatty acids in cottonseed oil: Fatty acids from cod liver oil, conjugated fatty acids from cod liver oil, eleostearic acid, linoleic acid and conjugated linoleic acid. A control group of animals received 0.3 cc. of cottonseed oil in the contralateral flank twice weekly for three months. Table XXXIX

Treatment

Died Without Tumors

Cottonseed oil—controls Fatty acids from cod liver oil Conjugated fatty acids from cod liver oil Eleostearic acid Linoleic acid Conjugated linoleic acid

Tumors

% With Tumors

4 3

31/36 33/37

86 89

6 10 0 6

15/34 24/30 29/40 25/34

44 80 72 73

In the third group of experiments (Table XL), four groups of 30 mice each were employed. Mixtures of the methylcholanthrene and of the fatty acids used were prepared by adding 0.5 cc. of the 5% fatty acids in cotton¬ seed oil solutions to 0.25 mg. of methylcholanthrene of 0.25% solution in tricaprylin. The injections were made subcutaneously immediately after mixing. Each animal received three injections at intervals of one week and Table XL

Treatment Methylcholanthrene + cottonseed oil Methylcholanthrene -f fatty acids from fish oil Methylcholanthrene -fconjugated fatty acids from fish liver oil Methylcholanthrene -f eleostearic and conjugated linoleic acid

Digitized by

Goo

% Residual Died WithFluorescence out Tumors

Tumors

% With Tumors ~ 86 ~

95

6

33/44

85

4

20/46

43

19

4

6/46

13

92

11

24/39

61

Onginal from

UNIVERSITY OF MICHIGAN

NOTES

/

709

the observations on tumor incidence were followed for 5 months. The fatty acids employed were fatty acids from fish oil, conjugated fatty acids from fish oil, a mixture of equal parts of eleostearic and conjugated linoleic acids, and cottonseed oil as a control. The quenching effect is shown as the percent of residual fluorescence of methylcholanthrene when mixed with the fatty acid mixtures. These results indicate a certain relationship between the quenching action of the conjugated fatty acids upon hydrocarbon carcinogens and the ability of fatty acids to reduce the carcinogenicity of these hydrocarbons. It is not sufficient to have a conjugated fatty acid present, in order to have the effect upon carcinogenesis. Eleostearic acid did not significantly reduce the incidence of tumors and conjugated linoleic acid was no more active than its nonconjugated isomer. Conjugated fish oil fatty acids (which contain di-, tri-, tetra-, pentaand hexanes) when mixed with methylcholanthrene reduced the tumor incidence to 13%, while a mixture of eleostearic and conjugated linoleic acid (di-, and triene conjugated acids) which have a limited quenching action gave an incidence of 61%. Although the incidence of tumors was much lower in the group receiving conjugated fish oil fatty acids, the non¬ conjugated fatty acids from the same source has a limited influence upon the cancer inducing property of the hydrocarbon. When fatty acids were not mixed with the carcinogen, but were injected separately, the noncon¬ jugated acids appeared without effect. Statistical analysis of the data from these three experiments show the following: the results are significant for the group treated with conjugated fatty acids from cod liver oil before and after methylcholanthrene was administered as compared with control group treated with cottonseed oil in Experiment I (*2 = 6.65 on basis of tumor/no tumor). In Experiment II, Table XLI Quenching of Methylcholanthrene 0.062% in Ethyl Alcohol by Substances Other Than Fatty Acids

Substance Glycerol n-Butanol Butyl mercaptan Hexyl mercaptan Dodecyl mercaptan Hexadecyl mercaptan Na thiosulfate Ethyl sulfate Nitrogen mustard Allyl K xanthate Nitromethane Ethylene trithiocarbamate Cholesterol

Digitized by

Google

% Dilution Used

Fluorescence

5.0 4.5 1.0 2.0 2.0 2.0 .05 cc. from 50% solution 1.0 0.1 1.0 1.0 1.0 1.0

106.8 96.4 102.5 92.0 82.0 70.0 97.0 95.0 79.9 3.8 7.4 .2 93.0

Original from

UNIVERSITY OF MICHIGAN

710

/

RESEARCH

IN

P H Y S I O PAT H O L O O Y

the results are very significant for the group treated with conjugated fatty acids of cod liver oil as compared with the control group (x2 = 13.09). In Experiment III, the results are very significant for all three groups in which fatty acids were added to the methylcholanthrene (x2 = 13.3, 41.56 and 8.32 respectively). When comparison is made on the basis of tumors/no tumors between groups receiving nonconjugated and conjugated isomers of the same fatty acid mixtures, the results were significant in all three experiments (x2 = 8 in Experiment I, 22 in Experiment II, and 12 in Experiment III). In the light of the relationship between quenching activity and the reduction of the carcinogenic activity, we are investigating different other agents. Table XLI shows the values of this effect. Chapter 12, Note 5. Lipids and Tumor Chlorides We submitted groups of mice grafted with DBA mammary adeno¬ carcinoma, to treatment with various lipoacids or positive lipoids prepara¬ tions. After ten days of treatment the tumors were removed and analyzed for their content of chlorides, using the Volhard technic, in which the titra¬ tion of silver nitrate was made electrometrically. As lipoacids, we used for experiment cod liver oil fatty acids, lipoacids from human placenta and butyl-mercaptan; for lipids with a positive character, we used cholesterol, insaponifiable fractions of human placenta and butanol. In all cases treated with lipoacids, the amount of chlorides was higher than in untreated con¬ trols. With cod liver oil fatty acids, values as high as 135% above those of controls were found. With the lipoacids of human placenta, the average value was 114% above that of controls; with mercaptans, 78% above. The influence exerted by the opposite lipids was much less manifest. With cholesterol and insaponifiable fractions, chloride values were 20% below those of controls; with butanol, 33% below. Chapter 12, Note 6. a-OH Fatty Acid and Experimental Tumors We studied the influence exerted by the series of alpha OH fatty acids, saturated and unsaturated, upon the evolution of different tumors in mice and rats, to find that only one member has a manifest effect which is lim¬ ited to a single tumor. Subcutaneous grafts of 6C3HED lymphosarcoma in C3H mice grew with abnormal rapidity. 48 hours after the transplant, the tumor could be felt. A very soft, highly edematous and, for this reason, diffuse tumor developed rapidly so that death occurred usually around the tenth day. This tumor was especially resistant to most of the chemothera¬ peutic agents tested. Daily administration of a 5% solution of alpha OH caprylic acid in a dose of 0.2-0.5 cc., started even the fifth day after the graft when the tumor was already well-developed, was followed by its rapid involution and disappearance in a high proportion of cases (55/60). In the few cases in which the tumor persisted, its evolution was very much changed. The animals remained alive for more than a month. If, after three

tized b> Google

UNIVERSITY OF MICHIGAN

NOTES

Days

711

11

8

5

/

Control Start treatnent Treated with